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 C
Explanation
A. Assessing pupillary response to light is not directly related to the administration of dopamine for hypotension and does not reflect the immediate effects of the medication on the cardiovascular or renal systems.
B. Seizure precautions are not a standard intervention for a patient receiving dopamine unless the patient has a history of seizures or there is another indication for such precautions.
C. Measuring urinary output every hour is essential as it reflects the patient's fluid balance and kidney function, which can be affected by dopamine administration. It is a direct measure of the effectiveness of the medication in improving renal perfusion and the patient's hemodynamic status.
D. While monitoring serum potassium levels is important in patients receiving IV therapy, it is not the most immediate concern when administering dopamine for hypotension, unless the patient has a known electrolyte imbalance.
Correct Answer is ["A","B","C","D"]
Explanation
Insufficient sleep, particularly due to nightmares, can exacerbate depression and should be addressed promptly.
Feeling "jumpy" or experiencing heightened anxiety, especially in situations reminiscent of the trauma, indicates a possible post-traumatic stress disorder (PTSD symptom.
A profound sense of sadness and numbness can be indicative of severe depression, requiring immediate attention.
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