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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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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

While nausea and vomiting can be side effects of eye surgery, they are not typically associated with acute pain deep within the eye following laser trabeculoplasty. Therefore, administering an antiemetic would not address the client’s primary complaint.

Choice B rationale

Acute pain deep within the eye following laser trabeculoplasty is not a typical postoperative symptom and could indicate a complication such as increased intraocular pressure or inflammation. Therefore, the nurse should report this complaint to the surgeon immediately for further evaluation.

Choice C rationale

While eye shields can help reduce photosensitivity after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.

Choice D rationale

While prophylactic antibiotics can help prevent infection after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.

A. The material is written at a twelfth-grade reading level. B. The material is printed using a 12-point type font. C. The material contains a list with definitions of unfamiliar terms. D. The material uses pictures to help illustrate complex ideas. E. The material uses common words with few syllables.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale

The material should not be written at a twelfth-grade reading level. Older adults may have varying levels of literacy, and health information should be accessible to all. It is recommended that patient education materials be written at a sixth-grade reading level or lower.

Choice B rationale

Using a 12-point type font can make the material easier to read, especially for older adults who may have vision problems.

Choice C rationale

Including a list with definitions of unfamiliar terms can help older adults understand the material better. Medical jargon can be confusing, and clear explanations of these terms can improve comprehension.

Choice D rationale

Pictures can help illustrate complex ideas and make the material more engaging and easier to understand. Visual aids can be particularly helpful when explaining how to take medication or demonstrating exercises.

Choice E rationale

Using common words with few syllables can make the material more accessible. Complex medical terms can be confusing, and using simple language can help ensure that the information is understood.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye.Which action should the nurse take?

Correct Answer is B

Explanation

When developing an educational program for older adult clients who are being discharged with new antihypertensive medications, which characteristics should the nurse ensure that the educational materials include? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

An elderly patient who had a fall at a store is admitted with a potential right hip fracture.What assessment finding should the nurse report to the healthcare provider?

A parent brings a 4-month-old infant to the clinic.The infant has had a runny nose, a slight fever, and a cough for the last two days.Which of the following findings should alert the nurse that the child is in acute respiratory distress?

An older adult client with dementia is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing.The client is becoming increasingly agitated and stating the UAP “wants to hurt me and tie me up.”. Which approach should the nurse use with this client?

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

A client newly diagnosed with type 1 diabetes mellitus (DM) asks the nurse to leave the room when the nurse tries to teach self-administration of insulin injections.What should the nurse do next?