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 []

Explanation

Potential Condition

- Dilated Cardiomyopathy: This condition is most likely because the client presents with symptoms of heart failure (chest pain, dizziness, inspiratory crackles, systolic murmur, and ankle edema) alongside a history of hypertension, which can contribute to the development of dilated cardiomyopathy.

Actions to Take

1. Apply Oxygen: The client is showing signs of potential heart failure, and oxygen can help alleviate symptoms associated with decreased oxygenation.

2. Perform 12-lead EKG: An EKG will provide information about any potential cardiac abnormalities, especially in the presence of chest pain and systolic murmur.

Parameters to Monitor

1. Blood Pressure: It is essential to monitor blood pressure due to the client's hypertension and heart failure symptoms, which may be exacerbated by elevated blood pressure.

2. Urine Output: Monitoring urine output helps assess kidney perfusion and fluid status, which can be affected by heart failure and hypertension, particularly in cases of cardiomyopathy.

A. Emphasize that using safe sex practices removes the risk of STIs. B. Clarify that all STIs are transmitted through sexual intercourse. C. Discuss that partners without similar symptoms may not be infected. D. Teach the importance of medication regimen and follow-up protocol.

Correct Answer is D

Explanation

A. While safe sex practices can significantly reduce the risk of STIs, they do not eliminate the risk entirely, especially with multiple partners involved.

B. This statement is misleading; not all STIs are transmitted solely through sexual intercourse, as some can also be transmitted through non-sexual means.

C. It is important to recognize that asymptomatic individuals can still be carriers of STIs; thus, this statement may provide false reassurance.

D. Teaching the client about the importance of following the medication regimen and attending follow-up appointments is critical for effective treatment of gonorrhea and preventing further transmission or complications. This approach prioritizes the client’s health and reinforces the need for responsible sexual practices.

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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

Correct Answer is []

Explanation

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

Correct Answer is D

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.