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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assigning the UAP to another client does not address the need for proper infection control measures when assisting the client with influenza.
B. Wearing a face mask is essential to prevent the transmission of respiratory droplets during close contact with the client with influenza. Reviewing the importance of wearing a face mask reinforces infection control practices.
C. Applying a fitted respirator mask may not be necessary for routine care of a client with influenza and may not be readily available for UAP use.
D. While important, monitoring the client's respiratory status does not directly address the need for infection control measures to prevent the spread of influenza.
Correct Answer is C
Explanation
A. Provide bedside equipment for transmission and protective precautions: While infection control precautions are important, obtaining cultures to identify the source of infection and guide treatment is the priority in this scenario.
B. Evaluate daily serum electrolytes and hydration status: While monitoring electrolytes and hydration is important in critically ill patients, it is not the priority in this situation where the client is presenting with signs of systemic infection.
C. Culture sputum, urine, burn wound, and all intravenous access sites: The priority is to obtain cultures to identify the source of infection, which will guide antibiotic therapy and other
interventions.
D. Implement central line-associated bloodstream infection: While preventing central line- associated bloodstream infection is important, it is not the priority in this situation where the client is presenting with signs of systemic infection.
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