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. Quiet, calm surroundings may be beneficial for clients recovering from various conditions, but it's not specifically significant for osteomalacia.
B. Stimulating sounds and activity are not directly related to the care of a client with osteomalacia.
C. Cool, moist air is not a significant factor in planning care for osteomalacia.
D. Adequate sunlight exposure is crucial for the synthesis of vitamin D, which is essential for calcium absorption and bone health. Therefore, ensuring the client receives adequate sunlight exposure is the most significant environmental factor for someone with osteomalacia
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
Explanation
Semi-Fowler's Position:This position involves the patient being partially seated (at a 30 to 45- degree angle) which aids in lung expansion and can ease breathing in patients with respiratory distress, making it the most appropriate choice for this patient.
Lung Expansion: Semi-Fowler's position helps to promote lung expansion by reducing pressure on the diaphragm, allowing for better expansion of the lungs and easier breathing.
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