The nurse reviews the client history of the presenting illness in the electronic medical record.

Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.

A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.

The client reports using a rescue inhaler three times, but he just couldn't catch his breath

symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous

inhaler was expired and was worried the medication was not working

able to answer questions, pausing every few words to catch his breath

The client reports that it has been a couple of months since he had an asthma attack

Answer and Explanation

The Correct Answer is ["A","B"]

In the provided scenario, the two key pieces of subjective data indicating the need for health interventions are the client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise. These details suggest that the client's asthma is not well-controlled, and the ineffectiveness of the rescue medication, especially with an expired inhaler, warrants immediate medical attention.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Protecting the skin of the radiation portal site from sunlight exposure is crucial to prevent further damage to the irradiated area, as the skin becomes more sensitive during radiation therapy.

B. Washing the skin inside the radiation portal site should be done gently with mild soap and water, as directed by the healthcare provider, to maintain cleanliness and prevent infection. However, excessive rubbing or scrubbing should be avoided to minimize irritation.

C. The ink marks of the portal are used as reference points for accurate delivery of radiation and should not be removed until instructed by the healthcare provider or radiation therapist.

D. Moisturizing the radiation portal site can help alleviate dryness and discomfort associated with radiation therapy, but it should be done sparingly and with products recommended by the healthcare provider to avoid potential interactions or interference with the treatment.

Correct Answer is ["125"]

Explanation

Correct Answer: 125 mL/hr

Rationale:

To calculate the infusion rate in mL/hr, you can use the formula: (Total Volume in mL) / (Time in hours) = Rate in mL/hr. For 1 liter (which is 1000 mL) of lactated Ringers to be infused over 8 hours, the calculation would be 1000 mL / 8 hr = 125 mL/hr.

Therefore, the nurse should program the infusion pump to deliver 125 mL of fluid per hour.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

Correct Answer is A

Explanation

A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["125"]

Explanation

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

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A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only)

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