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Exhibits

A nurse is assisting with the care of a client in the emergency department. The client is alert and oriented x3. Wheezing is noted on exhalation with a prolonged breathing cycle. The cough is nonproductive. Use of accessory muscles is noted while breathing. The oral mucosa and lips are cyanotic. Nasal flaring is noted. The client experiences difficulty talking.

The nurse is assisting in planning care. Complete the diagram by dragging from the choices below to specify:

  1. What condition the client is most likely experiencing.
  2. Two actions the nurse should take to address that condition.
  3. Two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Based on the provided information, here’s how the diagram should be completed:

  1. Condition the client is most likely experiencing:
    • Asthma
  2. Actions the nurse should take to address that condition:
    • Administer albuterol
    • Monitor ABGs
  3. Parameters the nurse should monitor to assess the client’s progress:
  • Oxygen saturation
  • Breath sounds


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Related Questions

Correct Answer is []

Explanation

Based on the provided information, here’s how the diagram should be completed:

  1. Condition the client is most likely experiencing:
    • Asthma
  2. Actions the nurse should take to address that condition:
    • Administer albuterol
    • Monitor ABGs
  3. Parameters the nurse should monitor to assess the client’s progress:
  • Oxygen saturation
  • Breath sounds

Correct Answer is A

Explanation

Choice A rationale

It is important for a client with diabetes mellitus to test the temperature of the water before bathing to prevent burns. People with diabetes often have neuropathy, which can reduce their ability to feel temperature changes, especially in their extremities. Therefore, using the wrist, which is more sensitive to temperature changes, can help ensure the water is not too hot.

Choice B rationale

Applying a heating pad to the feet is not recommended for people with diabetes. This is because the heat can cause burns, especially in those with neuropathy who may not be able to feel how hot the pad is.

Choice C rationale

Rounding the corners of toenails with a nail file is not recommended as it can lead to ingrown toenails. Instead, toenails should be cut straight across to avoid this.

Choice D rationale

While it’s important to keep skin moisturized to prevent dryness and cracking, lotion should not be applied between the toes. This area can stay moist and warm, creating an ideal environment for fungal infections.

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