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Exhibits

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Discuss aggressive respiratory treatment options

Obtain a sputum culture

Monitor the oxygen saturation

Allow the client to take a position of comfort

Wean the supplemental oxygen

Prepare for deep tracheal suctioning

Consider positive pressure ventilation

Discuss with the client potential asthma triggers

Answer and Explanation

Correct Answer : B,C,D,E,H

A. While discussing treatment options is important, it may not be immediately necessary at this point unless the client shows signs of severe respiratory distress or failure.

B. Given the client's respiratory distress and recent cold symptoms, obtaining a sputum culture can help identify any underlying infection, which is important for appropriate treatment, particularly with the prescribed azithromycin.

C. Continuous monitoring of oxygen saturation is essential to ensure that the client's oxygen levels are adequate, especially since she is at risk for hypoxia. The goal is to maintain oxygen saturation greater than 94%.

D. Positioning the client in a way that enhances her comfort, such as sitting upright, can help improve her breathing and reduce respiratory distress. This is a fundamental nursing intervention in respiratory care.

E. If the client's oxygen saturation improves, the nurse can begin to wean the supplemental oxygen while monitoring for any signs of respiratory distress. This step should be approached cautiously to ensure the client maintains adequate oxygen levels.

F. There is no indication that the client requires deep tracheal suctioning at this moment. This action is reserved for patients with excessive secretions or compromised airway patency.

G. Positive pressure ventilation would typically be considered if the client were in severe respiratory distress or failure. The current assessment does not indicate an immediate need for this intervention.

H. Education on potential asthma triggers is crucial for the client's long-term management. This discussion can help the client avoid situations that could lead to future exacerbations, thus improving her overall asthma control.

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Correct Answer is []

Explanation

Anorexia Nervosa

The client's symptoms, such as low body weight (BMI of 16.8 kg/m²), bradycardia (HR of 48 bpm), hypothermia (temperature of 96.2°F), poor muscle tone, irregular menstruation, and the presence of lanugo, all strongly suggest anorexia nervosa. Additionally, the client's refusal to acknowledge weight loss and her distorted perception of body image further support this diagnosis.

Actions the Nurse Should Take:

Educate on the condition:

The nurse should educate the client and her family about the physical and psychological aspects of anorexia nervosa, including the risks of severe malnutrition, electrolyte imbalances, and long-term complications if not treated.

Acknowledge anxious feelings:

The nurse should validate the client’s anxious feelings about food and body image, providing emotional support and promoting a therapeutic relationship to encourage the client to engage in treatment.

Parameters to Monitor:

Weight:

Monitoring the client’s weight regularly is essential to assess nutritional progress and to detect any further weight loss or gains.

Achievement of 100% of ideal weight:

Assessing whether the client is progressing toward achieving a healthy weight (100% of ideal body weight) is a critical marker of recovery from anorexia nervosa.

A. Blood pressure trend is downward and pulse is rapid and irregular. B. The pressure dressing at right femoral area is moist and oozing blood. C. Pulse distal to the femoral artery is weaker on left foot than right foot. D. Right foot is cool to the touch and appears pale and blanched.

Correct Answer is D

Explanation

A. A downward trend in blood pressure and a rapid, irregular pulse may indicate general hemodynamic instability but are not specific to arterial obstruction.

B. A moist and oozing dressing can indicate bleeding but does not directly suggest arterial obstruction.

C. A weaker pulse in the left foot compared to the right foot could indicate a vascular issue but not necessarily arterial obstruction specifically in the right leg.

D. A cool, pale, and blanched right foot indicates compromised blood flow and is a classic sign of arterial obstruction, warranting immediate assessment and intervention.

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Exhibits The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Complete the diagram by dragging from the choices area to specify condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse to assess the client's progress.

Correct Answer is []

Explanation

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

Correct Answer is D

Explanation

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

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?

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?

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.

A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever and cough for the last two days. Which finding should alert the nurse that the child is in acute respiratory distress?

Exhibits

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Which action(s) should the nurse plan for the rest of the shift? Select all that apply.