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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 {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

Let’s analyze the data collection findings to determine if they are consistent with hypovolemic shock or pulmonary embolism:

  1. Respiratory effort:
    • Hypovolemic Shock: ✔
    • Pulmonary Embolism: ✔
  2. Heart rate:
    • Hypovolemic Shock: ✔
    • Pulmonary Embolism: ✔
  3. Pain:
    • Pulmonary Embolism: ✔
  4. Blood pressure:
    • Hypovolemic Shock: ✔
  5. Mentation:
    • Hypovolemic Shock: ✔
    • Pulmonary Embolism: ✔

Each finding can support more than one condition, and there must be at least one selection in every column.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

Based on the provided information, the nurse should anticipate a provider prescription for 0.9% sodium chloride and Lorineiv 4mg every 4h.

This is because the patient is postoperative and may require fluid replacement to maintain hydration and manage mild discomfort.

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