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.

Apply a nonrebreather oxygen mask.

Increase oxygen flow.

Raise the head of the bed.

Take and monitor vital signs.

Administer additional nebulizer treatment as prescribed.

Provide client incentive spirometer and instruct on use

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Apply a nonrebreather oxygen mask. This will help increase the oxygen concentration delivered to the client's lungs and improve oxygen saturation.

B. Increase oxygen flow. Increasing the oxygen flow rate can help to further improve oxygen delivery.

C. Raise the head of the bed. This can help improve lung expansion and facilitate breathing.

D. Take and monitor vital signs. This will help assess the client's response to interventions and identify any deterioration.

E. Administer additional nebulizer treatment as prescribed. If the client's symptoms are not improving, additional nebulizer treatments may be necessary.

F. Provide client incentive spirometer and instruct on use: While incentive spirometry can be helpful in preventing atelectasis, it is not a priority in this acute situation where the client's immediate need is to improve oxygenation and reduce airway obstruction.

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Correct Answer is ["A","D","E"]

Explanation

A. Administer medications as prescribed. This includes the albuterol/ipratropium nebulizer treatment and oral prednisone, which are essential for managing acute asthma exacerbations.

B. Ask the client for a list of current medications: While this information is important, it is not the immediate priority in managing an acute asthma exacerbation.

C. Notify the healthcare provider of the client's need for intubation: Intubation is a more invasive procedure and is typically reserved for severe cases of respiratory distress that are not responding to medical therapy. In this case, the client's condition is not severe enough to warrant immediate intubation.

D. Apply oxygen via nasal cannula. The client's oxygen saturation is below 94%, indicating hypoxemia, and supplemental oxygen is necessary to improve oxygenation.

E. Provide client teaching. This includes educating the client about asthma triggers, medication adherence, and early signs of an asthma exacerbation.

F. Place the client in Trendelenburg position: This position is not indicated for asthma exacerbations. It is typically used for conditions like shock or hypotension.

Correct Answer is []

Explanation

Potential Condition:

Rheumatoid arthritis (RA):
- RA is a chronic autoimmune disorder that causes inflammation in the joints, leading to pain, stiffness, and swelling.
- The patient has several classic signs of RA:
  - Pain and stiffness in bilateral hands and wrists: A hallmark of RA, particularly in the morning (worse upon waking).
  - Positive rheumatoid factor and positive antinuclear antibody: Both are commonly seen in RA.
  - Elevated erythrocyte sedimentation rate (ESR): This indicates inflammation, which is typical in RA.
  - X-ray findings of soft tissue swelling and marginal erosions: These are common in RA and suggest joint damage.

Actions to Take:

Educate on disease process and management:
- It’s essential for the nurse to educate the patient on RA, its chronic nature, and the need for lifelong management. This will include medication adherence, managing flare-ups, and joint protection techniques.
Consult dietician for nutrition and weight loss:
- Obesity can exacerbate RA symptoms due to increased joint stress. Encouraging weight loss can help reduce strain on affected joints and improve overall health. A dietician can help with weight management strategies and recommend anti-inflammatory foods.

Parameters to Monitor:

Pain:
- Monitoring pain levels regularly is critical for assessing the effectiveness of treatment and making necessary adjustments to the pain management plan (e.g., the ibuprofen regimen).
Blood glucose:
- Since the patient has a BMI of 31, there is an increased risk for type 2 diabetes mellitus, which is common in patients with RA. Additionally, if the patient is prescribed corticosteroids for RA management, monitoring blood glucose is crucial, as corticosteroids can elevate blood sugar levels

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, which action(s) should the nurse anticipate? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

Correct Answer is []

Explanation

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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.