A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all that apply.)

The student needs to go to the hospital.

The nurse should obtain a second expiratory flow rate.

The student's peak flow is 50% to 80% of his best peak flow.

The student should use his quick-relief inhaler.

The student's asthma is not well controlled,

Answer and Explanation

Correct Answer : B,C,D,E

Asthma action plans often use a color-coded system to guide management based on peak expiratory flow rate (PEFR) measurements. The zones are typically green (80-100% of personal best), yellow (50-79% of personal best), and red (less than 50% of personal best).

A. The student needs to go to the hospital.

This is not necessarily required when the student is in the yellow zone. The yellow zone indicates caution and the need for intervention, but it does not immediately require hospitalization unless symptoms worsen or do not improve after using the quick-relief inhaler.

B. The nurse should obtain a second expiratory flow rate.

Confirming the peak flow measurement with a second reading ensures accuracy and helps to make informed decisions about the student's asthma management.

C. The student should use his quick-relief inhaler.

In the yellow zone, indicating moderate impairment, the use of a quick-relief (rescue) inhaler is often recommended to relieve symptoms and prevent progression to the red zone.

D. The student's peak flow is 50% to 80% of his best peak flow.

This is the correct range for the yellow zone, indicating moderate impairment. Action is needed to prevent worsening.

E. The student's asthma is not well controlled.

Being in the yellow zone indicates that the asthma is not well controlled and may require adjustments in the long-term management plan, including possible changes to daily controller medications.

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Correct Answer is C

Explanation

A. Impaired tissue perfusion: While impaired tissue perfusion is a concern in clients with varicose veins, the presence of ulcerations indicates that skin integrity is already compromised. Addressing impaired skin integrity is a more immediate concern.

B. Alteration in activity tolerance: Alteration in activity tolerance may be a consequence of impaired tissue perfusion and impaired skin integrity, but the priority is to address the current skin breakdown and prevent further complications.

C. Impaired skin integrity: This is the correct answer. The presence of varicose veins, ulcerations, and lower extremity edema indicates compromised skin integrity. The nurse should prioritize interventions to promote wound healing, prevent infection, and address the underlying causes contributing to impaired skin integrity.

D. Alteration in body image: While body image concerns may arise in clients with varicose veins, the immediate priority is addressing the physical complications such as impaired skin integrity to prevent further deterioration.

A. Excessive thrombosis and bleeding B. Increased clotting factors C. Progressive increase in platelet production D. Immediate sodium and fluid retention

Correct Answer is A

Explanation

A. Excessive thrombosis and bleeding

Disseminated Intravascular Coagulation (DIC) is a complex and serious condition characterized by widespread activation of the coagulation cascade, leading to both excessive clot formation (thrombosis) and simultaneous consumption of clotting factors and platelets, resulting in bleeding. DIC can occur as a secondary complication to various conditions such as sepsis, trauma, or obstetric complications.

B. Increased clotting factors: In DIC, there is consumption and depletion of clotting factors, not an increase.

C. Progressive increase in platelet production: Platelet production does not increase in DIC; instead, there is consumption and decreased platelet count.

D. Immediate sodium and fluid retention: DIC is not associated with immediate sodium and fluid retention; instead, it is characterized by fluid loss due to bleeding.

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A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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