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:
- What condition the client is most likely experiencing.
- Two actions the nurse should take to address that condition.
- Two parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
Based on the provided information, here’s how the diagram should be completed:
- Condition the client is most likely experiencing:
- Asthma
- Actions the nurse should take to address that condition:
- Administer albuterol
- Monitor ABGs
- Parameters the nurse should monitor to assess the client’s progress:
- Oxygen saturation
- Breath sounds
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The statement “Stop taking the medication if you feel drowsy” is incorrect. Drowsiness is not a common side effect of levothyroxine, and stopping the medication abruptly can lead to withdrawal symptoms and a rebound of hypothyroid symptoms.
Choice B rationale
The statement “Expect to take this medication for 4 to 6 weeks” is incorrect. Levothyroxine is typically a lifelong therapy for individuals with hypothyroidism, not a short-term treatment.
Choice C rationale
The statement “This medication may cause permanent hair loss” is incorrect. While hair loss can be a side effect of levothyroxine, it is usually temporary and resolves as the body adjusts to the medication.
Choice D rationale
Weighing oneself at the same time every day is a good practice when taking levothyroxine. This can help monitor for changes in weight, which could indicate that the dose of levothyroxine needs adjustment.
Correct Answer is C
Explanation
Offering snacks that are high in sodium is not recommended for patients with heart failure. Sodium can cause fluid retention and worsen heart failure symptoms.
Choice B rationale
Monitoring the patient’s weight once per week is not sufficient for patients with heart failure. Daily weight monitoring is typically recommended to detect fluid retention early.
Choice C rationale
Providing rest periods throughout the day is recommended for patients with heart failure. Rest can help reduce the workload of the heart and manage symptoms of fatigue.
Choice D rationale
Placing the head of the patient’s bed flat is not recommended for patients with heart failure. This position can make breathing more difficult. Instead, the head of the bed should be elevated.
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