Exhibits
Click to highlight the assessment findings that require immediate follow up by the nurse.
Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.
mild subcostal retractions
Wheezes are noted throughout the lung fields
The client is pale
She has strong peripheral pulses that are equal bilaterally
oxygen saturation 91% on room air
heart rate is 122 beats/minute
The Correct Answer is ["A","B","C","E","F"]
Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.
Rationale:
An oxygen saturation level of 91% indicates hypoxemia, which is concerning and requires immediate intervention. Normal oxygen saturation levels should be between 95% and 100%. The nurse should assess the client further and consider supplemental oxygen or other interventions to improve oxygenation.
Wheezing suggests bronchoconstriction, indicating that the client is experiencing significant respiratory distress. Given her history of asthma and the ineffectiveness of her usual albuterol dose, further assessment and potential escalation of treatment (such as systemic corticosteroids or nebulized medications) are warranted.
Pallor can be a sign of decreased perfusion or oxygenation and may indicate a worsening respiratory condition. This finding requires further evaluation of vital signs and potential interventions to address the underlying cause.
Tachycardia (elevated heart rate) may indicate stress or inadequate oxygenation, especially in the context of respiratory distress. The nurse should monitor the client's cardiovascular status closely and consider the need for interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. A full pitcher of water poses a risk for fluid overload, which can exacerbate heart failure symptoms.
B. A saline lock is standard for potential IV access and does not require immediate intervention.
C. A low sodium diet is appropriate for heart failure management.
D. Having a bedside commode is helpful for the client’s comfort and safety.
E. The supine position can increase venous return and worsen heart failure symptoms; the client should be positioned upright to facilitate breathing.
Correct Answer is ["21"]
Explanation
To calculate the flow rate for an IV infusion, you can use the formula: (Volume in mL / Time in minutes) * Drop factor (gtt/mL) = Flow rate (gtt/min). For a prescription of 1 L (which is 1000 mL) of lactated Ringer's to be infused over 12 hours (which is 720 minutes), and an IV administration set that delivers 15 gtt/mL, the calculation would be: (1000 mL / 720 minutes) * 15 gtt/mL = 20.83, which rounds to 21 gtt/min.
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