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

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Free Nursing Study Resources

Correct Answer is ["18"]

Explanation

To determine the infusion rate in mL/hr, you can use the following formula: (Desired Dose (units/hr) / Concentration of drug in IV bag (units/mL)) = Infusion rate (mL/hr). For the given prescription of heparin 900 units/hr, and an IV bag containing 25,000 units of heparin in 500 mL of solution, the concentration is 25,000 units / 500 mL = 50 units/mL. Using the formula: 900 units/hr / 50 units/mL = 18 mL/hr.

A. Encourage client to implement relaxation techniques. B. Refer client to the social worker for support therapy. C. Leave the client's room and return later in the day. D. Explain that insulin is a life-saving drug for the client.

Correct Answer is C

Explanation

A. While encouraging relaxation techniques can be helpful, the client’s immediate expression of frustration indicates a need for the nurse to respect their request.

B. Referring the client to a social worker may be beneficial in the long term but does not address the immediate situation.

C. Leaving the client’s room and returning later respects the client's wishes and allows for a more conducive environment for teaching when the client is ready.

D. Explaining the importance of insulin may not be effective if the client is currently unwilling to engage in the discussion.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["18"]

Explanation

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

Correct Answer is C

Explanation

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (Rank the first action at the top with the remainder in descending order.)

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

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