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