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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Reinforce the need for adequate hydration: Adequate hydration is essential for liquefying secretions in the lungs, especially in clients with COPD who may have increased mucus production. Proper hydration also supports cardiovascular function, particularly in clients with peripheral vascular disease.

B. Provide typed instructions for healthy diet selections: While diet is important for overall health, hydration is the priority in this scenario due to the client's respiratory and vascular conditions.

C. Explain a daily regimen: While educating the client about a daily regimen is important, ensuring adequate hydration takes precedence in this situation.

D. Demonstrate specific strengthening exercises: While exercise is beneficial for clients with COPD and PVD, ensuring proper hydration is more critical for respiratory and cardiovascular function in this scenario.

A. The client will report pain less than 3/10 B. The client will have quit smoking C. The client will remain free of skin breakdown D. The client will maintain oxygen saturation of 96% without supplemental oxygen E. The client will be afebrile for 24 hours

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

Explanation

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Naxlex Comprehensive Predictor Exams

A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD and peripheral vascular disease (PVD is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement?

Correct Answer is A

Explanation

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

Explanation

A6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy, Which pre- operative nursing action has highest priority?

The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings, as seen in the video. Which action(s) should the charge nurse take? (Select all that apply)

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre- operative nursing action has the highest priority?

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding the care of this client?

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive person (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?