The client is a 49-year-old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the emergency department (ED last night when he was having more difficulty breathing. He has a history of one-half pack a day cigarette smoking for 20 years. He has no significant medical or surgical history
The client has an oxygen saturation of 96% on 8 L simple face mask. The nurse assesses the client, and he is feeling less restless and anxious. His heart rate is now 79 bpm, blood pressure 119/73 mmHg, and respiratory rate 24.
What are the 3 most important goals that would help the nurse evaluate the treatment of this client at discharge?
The client will report pain less than 3/10
The client will have quit smoking
The client will remain free of skin breakdown
The client will maintain oxygen saturation of 96% without supplemental oxygen
The client will be afebrile for 24 hours
Correct Answer : B,D,E
A. While managing pain is important, the client did not report significant pain, making it a lower priority in this scenario.
B. Quitting smoking is crucial for the client's respiratory health, especially given the history of smoking and current respiratory symptoms.
C. There is no indication that the client is at risk of skin breakdown; thus, it is not a priority in the immediate discharge plan.
D. Maintaining an oxygen saturation of 96% without supplemental oxygen is a direct indicator of improved respiratory function and a key goal for discharge.
E. Being afebrile for 24 hours would indicate that the infection is under control, which is a primary concern for discharge after presenting with flu-like symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Assess pupillary response to light hourly: Dopamine administration may cause changes in pupillary response, but it is not the primary concern associated with its administration. Hourly pupillary assessment may not be necessary unless other signs of neurological changes are present.
B. Initiate seizure precautions: While dopamine administration may cause neurological effects, such as agitation or tremors, it is not typically associated with seizure activity. Seizure precautions are not indicated solely due to dopamine infusion.
C. Monitor serum potassium frequently: Dopamine administration can affect potassium levels, but monitoring serum potassium levels frequently may not be necessary unless the client has pre- existing potassium imbalances or is at risk for electrolyte disturbances.
D. Measure urinary output every hour: Dopamine is a vasopressor medication that can increase blood pressure and cardiac output, potentially leading to increased renal perfusion and urinary output. Monitoring urinary output hourly is essential to assess the client's response to dopamine therapy and ensure adequate renal function.
Correct Answer is C
Explanation
A. Notify the emergency response team of the client's seizure: While the seizure is significant, it lasted less than 1 minute and resolved spontaneously. There is no need to call an emergency response team unless complications arise or the seizure becomes prolonged.
B. Keep orienting the client to time and space until he is less confused: While supportive, this is not the priority. Postictal confusion is expected and does not usually require active reorientation until the client regains baseline status.
C. Explain the postictal state that usually follows seizures: Providing reassurance and education to the spouse about postictal symptoms (such as confusion, lethargy, and altered responsiveness) is appropriate and therapeutic. It addresses her concern while monitoring the client for further changes.
D. Ask the wife to wait outside the room until the nurse can talk with her: This action excludes the spouse unnecessarily and delays communication. Involving the family promotes trust and understanding.
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