Exhibits

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Take and monitor vital signs.

Administer additional nebulizer treatment.

Increase oxygen flow rate.

Raise the head of the bed.

Provide client with a spirometer for use.

Answer and Explanation

Correct Answer : B,C,D

Choice A reason: Monitoring vital signs is crucial to assess the client's current condition and detect any further deterioration. Changes in vital signs can indicate the effectiveness of the treatment and whether additional interventions are needed. For instance, if the heart rate continues to rise or oxygen saturation drops further, it suggests that the client's condition is worsening and requires immediate attention. Keeping a close eye on the vital signs helps the healthcare team to make timely decisions and adjust the treatment plan as necessary.

Choice B reason: Administering additional nebulizer treatment is necessary because the client is still experiencing shortness of breath and bilateral wheezes even after the initial medication. Nebulizer treatments, such as those containing albuterol and ipratropium, help to relax and open the airways, making breathing easier. Given the client's severe asthma symptoms and the fact that the previous doses were not completely effective, additional treatment can provide the needed relief and prevent further respiratory distress.

Choice C reason: Increasing the oxygen flow rate is essential to improve the client's oxygen saturation levels. The current oxygen saturation of 91% indicates hypoxemia, which can lead to severe complications if not addressed promptly. By increasing the flow rate, the client can receive a higher concentration of oxygen, helping to maintain adequate oxygenation of tissues and organs. Continuous monitoring of oxygen saturation is also important to ensure that the increased flow rate is effective and to make further adjustments if needed.

Choice D reason: Raising the head of the bed helps to facilitate easier breathing for the client. This position allows gravity to assist in the expansion of the lungs and reduces the pressure on the diaphragm, making it easier for the client to take deeper breaths. It also helps to reduce the work of breathing and can be particularly beneficial for clients experiencing respiratory distress. Ensuring that the client is in a comfortable and optimal position for breathing is an important aspect of asthma management.

Choice E reason: While providing a spirometer can be useful for lung function exercises, it is not the immediate priority in this acute situation. The client's primary concern is to stabilize their breathing and ensure adequate oxygenation. Once the client is stable, a spirometer can be introduced as part of long-term management and rehabilitation to improve lung function and monitor progress.

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Correct Answer is B

Explanation

Choice A reason: Administering a PRN dose of an antispasmodic agent can help relieve bladder spasms that often occur after TURP, but it does not address the immediate issue of blood clots blocking the drainage tubing. The primary concern is to ensure the patency of the catheter and proper drainage.

Choice B reason: Increasing the flow of the bladder irrigation is the best initial action. By increasing the flow, the nurse can help flush out the blood clots from the drainage tubing and ensure that the catheter remains patent. This action directly addresses the problem of blocked drainage and prevents further complications.

Choice C reason: Measuring the client's intake and output is important for overall monitoring, but it does not directly address the immediate concern of blood clots in the drainage tubing. Ensuring proper drainage is crucial to prevent complications such as bladder distention and further bleeding.

Choice D reason: Providing additional oral fluid intake is beneficial for maintaining hydration and promoting urine output, but it does not solve the problem of blood clots in the drainage tubing. The primary focus should be on ensuring the catheter's patency through irrigation.

A. Confirmation of the autoimmune disease process. B. Representative of a decline in the client's condition. C. Indication of the onset of joint degeneration. D. Evidence of spread of the disease to the kidneys.

Correct Answer is A

Explanation

Choice A reason: An elevated serum rheumatoid factor is most commonly associated with rheumatoid arthritis, an autoimmune disease. This finding supports the diagnosis and indicates the presence of autoantibodies that attack the body's own tissues. The rheumatoid factor is used as one of the diagnostic criteria for rheumatoid arthritis and confirms the autoimmune nature of the disease. It does not indicate disease severity or progression but rather the presence of the disease.

Choice B reason: An elevated serum rheumatoid factor is not necessarily representative of a decline in the client's condition. While high levels of rheumatoid factor can be present in individuals with active disease, they do not directly correlate with disease activity or progression. The presence of rheumatoid factor alone does not provide information about the current state or severity of the client's condition.

Choice C reason: An elevated serum rheumatoid factor does not indicate the onset of joint degeneration. Rheumatoid factor is an antibody that indicates the presence of an autoimmune response but does not directly cause joint damage. Joint degeneration in rheumatoid arthritis results from the chronic inflammation and immune response within the joints, leading to tissue damage over time. Rheumatoid factor is a marker of the disease but not a direct indicator of joint damage.

Choice D reason: An elevated serum rheumatoid factor is not evidence of the spread of the disease to the kidneys. Rheumatoid arthritis primarily affects the joints and can also have systemic manifestations, but the presence of rheumatoid factor is not indicative of kidney involvement. Kidney involvement in rheumatoid arthritis is relatively rare and would typically require additional diagnostic tests and clinical evaluation to determine.

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Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

Correct Answer is B

Explanation

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

Correct Answer is A

Explanation

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The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?

Exhibits The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

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A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?

A client who works at a computer most of the working day comes to the clinic reporting pain in both hands that causes the client to wake during the night. Which action should the nurse implement to assess for carpal tunnel syndrome?

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

Exhibits

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.