Patient Data
The nurse has identified the priority problem for the client and now must determine proper care interventions.
Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
Provide client teaching
Apply oxygen via nasal cannula.
Ask the client for a list of current medications.
Place the client in Trendelenburg position.
Notify the healthcare provider of the client's need for intubation.
Administer medications as ordered.
Correct Answer : A,B,C,F
A. Client education is also important, focusing on asthma management, the importance of carrying a non-expired inhaler, and avoiding known triggers.
B. Oxygen therapy via nasal cannula should be considered due to the patient's oxygen saturation of 88% on room air, aiming to maintain SpO2 above 94%.
C. Requesting a list of current medications is essential for reviewing potential drug interactions and ensuring comprehensive care.
D. Trendelenburg position is not indicated for this condition and could exacerbate breathing difficulties.
E. While the patient's condition should be closely monitored, the current information does not suggest an immediate need for intubation; however, the healthcare provider should be notified if the patient's condition worsens.
F. Administering medications as ordered is crucial to address the immediate respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Using a large gauge IV catheter can increase the risk of bleeding in a thrombocytopenic patient.
B. Wrapping bruised areas with elastic bandage dressings is not recommended as wrapping bruised areas with elastic bandages can cause additional pressure and potentially worsen bruising or bleeding.
C. While dietary modifications may be necessary for other reasons, removing cold and frozen foods does not address the immediate risk of bleeding associated with low platelet counts.
D. This is crucial because patients with thrombocytopenia are at an increased risk of bleeding, which may not always be visible or apparent. Regular monitoring can help in early detection and prompt management of any bleeding episodes.
Correct Answer is B
Explanation
A. Collecting the blood sample from a reddened and engorged fingertip may lead to inaccurate glucose readings and can cause discomfort to the client. Selecting another finger is a more appropriate action.
B. Selecting another finger ensures an accurate blood sample and minimizes discomfort to the client. It allows for a fresh puncture site that is not engorged, improving the accuracy of the glucose reading.
C. Applying pressure to the site may temporarily reduce engorgement but may not be sufficient to obtain an accurate blood sample. Selecting another finger is a more appropriate action.
D. Assessing radial pulse volume is not necessary in this situation, as the client's fingertip appearance does not indicate compromise of peripheral circulation.
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