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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Measuring vital signs is essential but does not address the immediate respiratory distress the client is experiencing.

B. Assisting the client to a high Fowler's position can significantly improve respiratory effort by allowing for better lung expansion and reducing pressure on the diaphragm.

C. While deep breathing exercises can be beneficial, they should be initiated after ensuring the client is in a position that facilitates easier breathing.

D. Auscultating breath sounds is necessary for further assessment, but prioritizing the client's comfort through positioning is the immediate action to take.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Hypoxia is suggested by the client’s oxygen saturation of 91% on room air, indicating inadequate oxygen levels in the blood.

Narrowed airway passages is likely due to her asthma exacerbation, as evidenced by the presence of wheezing throughout the lung fields and her previous ineffectiveness of albuterol to relieve her symptoms. This situation indicates bronchoconstriction, which contributes to airway narrowing and subsequent hypoxia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?

Correct Answer is B

Explanation

Exhibits Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. onsidering the client's history and assessment findings, it is likely the client has related to

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

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 fie me up." Which approach should the nurse use with the client?