Exhibits

After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions.

Which 2 prescriptions should the nurse complete first?

Perform pulmonary function test

Measure vital signs

Provide a regular diet tray

Give albuterol as ordered

Apply oxygen 1 L/minute

Answer and Explanation

Correct Answer : D,E

A.   Perform pulmonary function test
This is important for assessing lung function, but it is not an immediate priority during an acute exacerbation when the patient's oxygen saturation is low and they are experiencing respiratory distress.
Pulmonary function testing can be done once the patient's acute symptoms are stabilized.
B.   Measure vital signs
While vital signs are important for ongoing assessment, the patient's vital signs were already assessed at admission and are being monitored every 4 hours as per orders.
Administering oxygen and albuterol to stabilize the patient's condition takes precedence over routine vital sign checks immediately after the initial assessment.
C.   Provide a regular diet tray
This is a routine aspect of care and does not address the acute respiratory distress or hypoxemia that require immediate attention.
It can be done once the patient's respiratory status has stabilized.
D.   Give albuterol as ordered
The patient is experiencing an asthma exacerbation with wheezing and subcostal retractions. Albuterol is a bronchodilator that helps relieve bronchospasm and improve airflow.
It was ordered for nebulization now and every 4 hours PRN (as needed) for wheezing.
Administering albuterol promptly is crucial to help alleviate respiratory distress and improve lung function.
E.   Apply oxygen 1 L/minute
The patient's oxygen saturation is 91% on room air, which is below the target of greater than 94%. Oxygen therapy is indicated to correct hypoxemia and improve oxygen saturation.
The order specifies to titrate oxygen to keep saturation greater than 94%, starting at 1 L/minute via nasal cannula.

Nursing Test Bank

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Correct Answer is B

Explanation

Rationale

A. Although low serum albumin levels can impact wound healing, they are not directly related to the presence of purulent drainage.

B. Neutrophils are a type of white blood cell involved in the body's immune response, particularly against bacterial infections. An elevated neutrophil count (neutrophilia) can indicate an acute infection or inflammation, including in wounds.

C. High blood glucose levels can predispose the client to infections, including wound infections. While it's important to monitor blood glucose levels, it is less directly relevant to the immediate concern of purulent drainage from the burn wound.

D. Hematocrit measures the proportion of red blood cells in the blood and is used to assess hydration status and oxygen-carrying capacity. In burn patients, changes in hematocrit can indicate fluid shifts and potential dehydration. Fluid shifts and dehydration can influence wound healing and overall patient condition but are not directly related to the presence of purulent drainage.

A. I should have taken an extra dose of fluticasone- salmeterol. B. I should have taken some allergy medications before going on the hike. C. I have been very stressed out lately and should work on stress management. D. I should have eaten a snack halfway through the hike. E. My friend smoked cigarettes during the hike

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Correct choices are;

A.I should have taken an extra dose of fluticasone-salmeterol -No Understanding
Explanation: Fluticasone/salmeterol is a long-acting inhaler used for maintenance therapy in asthma. It is not meant to be used as a rescue medication for acute symptoms or exacerbations. Therefore, taking an extra dose in response to symptoms would not be appropriate.

B. I should have taken some allergy medications before going on the hike -Understanding
Explanation: Allergy medications, such as antihistamines or nasal sprays, can help reduce allergic triggers that can exacerbate asthma symptoms. Taking these medications before exposure to known triggers (like allergens during a hike) can help prevent an asthma exacerbation.

C. I have been very stressed out lately and should work on stress management -Understanding
Explanation: Stress is a known trigger for asthma exacerbations. Managing stress through techniques such as relaxation exercises, mindfulness, or therapy can help reduce the likelihood of triggering asthma symptoms.

D. I should have eaten a snack halfway through the hike - No Understanding
Explanation: While maintaining good nutrition and hydration is important for overall health, eating a snack would not necessarily prevent an asthma exacerbation unless the snack contained medications or substances that specifically manage asthma symptoms.

E. My friend smoked cigarettes during the hike - Understanding
Explanation: Secondhand smoke is a common trigger for asthma exacerbations. Being exposed to cigarette smoke can irritate the airways and worsen asthma symptoms.

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Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

Exhibits The nurse begins client education and asks the client what potential asthma triggers may have been involved in her recent exacerbation. For each statement click to specify if the client has an understanding or no understanding of asthma triggers. Each row must have one option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet? A Baked potato with skin, raw carrots.

A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

Exhibits

After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions.

Which 2 prescriptions should the nurse complete first?