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 A

Explanation

A. Eating patterns and dietary intake are crucial in managing chronic pancreatitis as certain foods can exacerbate symptoms. Identifying dietary triggers and making appropriate dietary modifications can help alleviate abdominal pain.

B. The activity level of bowel sounds may provide information about gastrointestinal motility but is not directly related to pain management in chronic pancreatitis.

C. Physical activity can impact overall health but may not directly alleviate abdominal pain associated with chronic pancreatitis.

D. The color and consistency of feces may indicate malabsorption or other gastrointestinal issues but may not directly address the client's pain management needs.

A. Increase IV fluids to 150 mL/hr B. Monitor for adverse reaction to antibiotics C. Repeat CD4+ T-cell count STAT D. Initiate airborne isolation E. Administer antiemetic

Correct Answer is ["A","B","E"]

Explanation

A. This intervention is likely to be ordered due to the patient's fever and elevated heart rate, which may suggest dehydration or the need for increased fluid intake to support hemodynamic stability and mitigate the effects of fever and potential dehydration from fever and nausea.

B. Given the diagnosis of Pneumocystis pneumonia, the patient will likely be on or start antibiotics specific to this infection, such as trimethoprim-sulfamethoxazole. Monitoring for adverse reactions is crucial, especially in a newly diagnosed HIV- positive patient who might be starting multiple new medications.
C. While it is important to monitor CD4 counts in HIV-positive patients to guide treatment decisions, repeating the CD4 count immediately might not be prioritized unless there are specific clinical changes that suggest a rapid decline in immune function. Given the recent test results showing a CD4 count of 443 cells/mm^3, immediate retesting might not be clinically justified unless guided by other symptoms or considerations not detailed here.
D. Pneumocystis pneumonia does not require airborne isolation as it is not typically contagious between people under normal circumstances. Instead, it arises as an opportunistic infection in individuals with weakened immune systems. Hence, this order would not be appropriate unless there were other infections suspected that require such precautions.
E. The patient reports severe nausea, which not only is distressing but can also prevent the patient from taking oral medications and maintain necessary nutrition. Administering an antiemetic can help manage this symptom effectively.

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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 caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

Correct Answer is A

Explanation

Patient Data Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

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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.

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

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.