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The client is a 22-year-old female with a history of asthma.

She was diagnosed at the age of 4 years old and has 2 previous hospitalizations for asthma related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week.

She reports taking edible marijuana to relieve severe premenstrual symptoms.

She came to the emergency department when she started having difficulty breathing on a hike.

She took her usual dose of albuterol, but the symptoms did not resolve.

The client’s friend called an ambulance when they noticed her difficulty in breathing.

Click to highlight the assessment findings that require immediate follow up by the nurse.

The client is admitted to the medical floor.

She has mild subcostal retractions and is sitting in an upright position.

Wheezes are noted throughout the lung fields.

The client is pale.

She has strong peripheral pulses that are equal bilaterally.

Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg. Oxygen saturation is 91% on room air.

She has mild subcostal retraction

sitting in an upright position

Wheezes are noted throughout the lung fields

The client is pale

Her heart rate is 122 beats/minute

Oxygen saturation is 91% on room air

strong peripheral pulses that are equal bilaterally

client is admitted to the medical floor

blood pressure 134/85 mm Hg

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

The assessment findings that require immediate follow up by the nurse are: The client has mild subcostal retractions. This could indicate that she is using accessory muscles to breathe, which is a sign of respiratory distress. The client is sitting in an upright position. This is a common position for people who are having difficulty breathing because it allows for maximum expansion of the lungs. Wheezes are noted throughout the lung fields. Wheezing can be a sign of an obstructive process such as asthma. The client is pale. Paleness can be a sign of decreased oxygenation. Her heart rate is 122 beats/minute, which is above the normal range and can indicate that her body is working harder to get oxygen. Her oxygen saturation is 91% on room air. Normal oxygen saturation is generally 95% or higher, so this could indicate that she is not getting enough oxygen.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

The patient vomiting at home for 3 days prior to surgery is crucial information that the PACU nurse should report. This could indicate a pre-existing condition or complication that needs to be addressed in the patient’s post-operative care plan.

Choice B rationale

While the patient refusing to take ice chips despite complaining of dry mouth is an important observation, it is not as critical as the patient’s pre-operative condition (vomiting for 3 days). The refusal of ice chips could be addressed through patient education and encouragement.

Choice C rationale

The presence of peripheral pulses and full range of motion in both legs is expected and normal in a post-operative patient, unless there were complications during surgery that could affect these observations. Therefore, this information, while important, is not as critical as the patient’s pre-operative condition.

Choice D rationale

The condition of the patient’s abdomen (soft, bowel sounds absent) and the absence of bleeding on the dressing are expected observations in a patient who has undergone an exploratory laparotomy. These observations, while important, do not provide additional critical information that the PACU nurse should report.

A. Replace paper trash bags with plastic biohazard bags. B. Remove soft drink cans from the nurse’s desk and patient lounge. C. Confiscate the patient’s cellular phone and provide a room telephone. D. Ensure that prescribed medications are securely stored in the room.

Correct Answer is D

Explanation

Choice A rationale

Replacing paper trash bags with plastic biohazard bags is not typically necessary in a mental health unit unless there is a risk of exposure to blood or other potentially infectious materials. This action would not specifically address the safety needs of a patient with depression following a positive HIV diagnosis16.

Choice B rationale

Removing soft drink cans from the nurse’s desk and patient lounge is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. This action does not directly address the patient’s mental health needs16.

Choice C rationale

Confiscating the patient’s cellular phone and providing a room telephone is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. While some facilities may have policies regarding the use of personal electronic devices, this action does not directly address the patient’s mental health needs16.

Choice D rationale

Ensuring that prescribed medications are securely stored in the room is the correct action. This is a standard safety measure in healthcare settings to prevent medication errors and misuse. It is particularly important for patients with depression who may be at risk for self-harm16.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A patient is admitted to the mental health unit due to feelings of depression following a positive HIV diagnosis.Which action should the nurse take to ensure a safe environment for this patient?

Correct Answer is D

Explanation

Following the administration of albuterol and the subsequent assessment, what actions should the nurse plan for the rest of the shift?

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Exhibits For each statement, specify if the client has an understanding or no understanding of asthma triggers. Each row must have one option selected.

Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.