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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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale

Determining the amount of weight the patient has lost since increasing activity is relevant to the patient’s overall health and progress toward weight loss goals, but it does not directly address the issue of sleep difficulties. Weight loss and improved sleep may not always have a direct cause-and-effect relationship.

Choice B rationale

Inquiring about the patient’s exercise schedule is a reasonable action. It allows the nurse to gather information about the patient’s exercise routine and assess whether it might be contributing to the sleep difficulties. For instance, exercising too close to bedtime can interfere with sleep. Therefore, understanding the timing and intensity of the patient’s exercise can provide valuable insights into potential adjustments that could improve sleep quality.

Choice C rationale

Informing the patient that lifestyle changes often take several weeks to be effective is a general statement that might not address the specific concerns of the patient. While it’s true that lifestyle changes, including exercise, can take time to show results, this does not provide a targeted solution to the patient’s reported difficulty in falling asleep.

Choice D rationale

Encouraging the patient to exercise daily to reduce bedtime wakefulness is not appropriate advice in this scenario. It oversimplifies the issue and may not address the underlying causes of the patient’s sleep difficulties. Additionally, excessive exercise close to bedtime may actually interfere with sleep.

A. Cefazolin 1 gram intravenously every 6 hours. B. Complete blood cell count (CBC) in the morning. C. Straight catheterization if unable to void. D. Advance from clear liquids as tolerated.

Correct Answer is A

Explanation

The correct answer is A. The nurse should first implement the prescription of Cefazolin 1 gram intravenously every 6 hours.

This is because, on admission of a patient to the postanesthesia care unit (PACU) from surgery, the first priority is to assess the airway and breathing status. Administering Cefazolin, an antibiotic, helps prevent postoperative infections, which is crucial in the immediate postoperative period.

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Naxlex Comprehensive Predictor Exams

A patient informs the nurse about starting an exercise program a month ago to lose weight and improve sleep.The patient states, “It still takes at least two hours to fall asleep at night.”. What action should the nurse take?

Correct Answer is B

Explanation

The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit.Which prescription should the nurse implement first?

Correct Answer is A

Explanation

A patient taking temazepam informs you, the nurse, of plans to quit taking the medication due to feelings of being “hungover” the next day.What action should you implement?

While preparing to administer a scheduled IV medication, a client complains of pain at the IV site and refuses a flush to assess the site.What should the nurse do next?

The nurse is caring for a child with mononucleosis.Which symptoms should the nurse expect the child to exhibit?

While changing a postoperative patient’s dressing, the nurse notices purulent drainage at the site.Before reporting this to the healthcare provider, which of the patient’s lab values should the nurse check?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest.Which action should the nurse take?

A patient with metastatic cancer who was taking hydromorphone orally at home is now receiving the medication intravenously while in the hospital.To evaluate if the patient is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?