Patient Data

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Asking about the effectiveness of antifungal creams is not relevant to herpes zoster, which is caused by the varicella-zoster virus.

B. Inquiring about family members sharing combs and brushes is not directly related to herpes zoster, as it is not transmitted through sharing personal items.

C. Asking about dry patches on the feet and hands may provide information about other dermatological conditions but does not specifically address herpes zoster.

D. Asking whether everyone at home has already had varicella is important because herpes zoster, commonly known as shingles, is caused by reactivation of the

varicella-zoster virus, which also causes chickenpox (varicella). Individuals who have not had chickenpox or been vaccinated against it may be at risk of developing chickenpox if exposed to herpes zoster lesions.

A. Assess the pin sites for signs of infection. B. Administer pain medication at designated intervals around the clock. C. Assess the pulses proximal to the fracture site. D. Remove traction every shift and provide skin care.

Correct Answer is A

Explanation

A. Assessing the pin sites for signs of infection is essential in clients with skeletal traction to detect any early signs of infection, such as redness, swelling, warmth, or purulent drainage. Prompt identification and management of pin site infections can prevent complications.

B. Administering pain medication at designated intervals around the clock helps to ensure adequate pain control and comfort for the client. However, this intervention alone does not specifically address the care needs related to skeletal traction.

C. Assessing the pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this assessment is not directly related to the care of skeletal traction itself.

D. Removing traction every shift is not indicated unless there is a specific reason to do so as ordered by the healthcare provider. Continuous traction is often necessary for proper alignment and stabilization of the fracture. Additionally, providing skin care is important to prevent skin breakdown around the traction device, but removing traction every shift is not part of routine care.

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Patient Data Exhibits 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

Correct Answer is D

Explanation

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

Correct Answer is A

Explanation

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Patient Data Exhibits Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.

Patient Data

Exhibits

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.