Exhibits

The nurse has completed a client history and initial assessment and is now planning on prioritizing care of the client.

Complete the following sentences by choosing from the list of corresponding options

Based on the history and assessment data, the nurse should prioritize
dropdown
as the priority problem for this client, as evidenced by the client's statement,
dropdown
.

Answer and Explanation

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

Rationale for Correct Choices

Option 1: Impaired gas exchange is the priority problem because the client's oxygen saturation is critically low at 88%, and the assessment reveals expiratory wheezes, rapid respirations (28/min), and severe shortness of breath. These indicate difficulty in maintaining adequate oxygenation.

Option 2: "I used my rescue inhaler three times, but I couldn’t catch my breath." This statement directly indicates that the asthma attack is unresponsive to the usual medication, highlighting the severity of the impaired gas exchange.

Rationale for Incorrect Choices

Option 1:

A. Anxiety: While anxiety may be present, it is a secondary issue caused by the asthma attack and is not the root cause of the client’s symptoms.

C. Ineffective airway clearance: Although wheezing suggests partial obstruction, the critical issue is the impaired oxygenation and low oxygen saturation rather than mucus or secretions obstructing the airway.

D. Activity intolerance: The client’s difficulty breathing is not primarily due to exertion but rather to the asthma attack itself.

Option 2:

A. "I was jogging when it started.": This identifies the trigger for the attack but does not explain the severity or lack of response to medication.

C. "My symptoms are worse when outdoors and when exercising.": This is helpful for identifying long-term triggers but does not prioritize the immediate issue of unrelieved shortness of breath.

D. "I noticed my inhaler was expired and was worried the medication was not working.": While this points to a lapse in medication management, it does not address the acute respiratory distress.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Central line insertion is not the appropriate intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates airway obstruction, which requires immediate airway management, not central venous access.

Choice B reason: Nasogastric tube (NGT) insertion is not the correct intervention for stridor. NGT insertion is typically used for gastrointestinal decompression or feeding, not for managing airway obstruction.

Choice C reason: Tracheostomy placement is the correct intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates a potential airway obstruction, which can be life-threatening. A tracheostomy provides a secure airway and ensures adequate ventilation.

Choice D reason: Pacemaker placement is not relevant to managing stridor. Pacemakers are used for cardiac rhythm management and do not address airway obstruction.

A. Temperature: 98.9°F B. Heart rate: 112 beats per minute C. Respirations: 28 breaths per minute D. Blood pressure: 130/86 mmHg E. Oxygen saturation: 88%

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

Explanation

Temperature: 98.9°F

Neither Disease Process Nor Medication Use:
The temperature is within normal range and does not indicate an infection or other abnormality.

Heart Rate: 112 beats per minute

Disease Process:
The elevated heart rate (tachycardia) is most likely due to the asthma attack, which increases respiratory effort and oxygen demand. Anxiety from the attack could also contribute.

Respirations: 28 breaths per minute

Disease Process:
The elevated respiratory rate (tachypnea) is consistent with the asthma attack and respiratory distress, a hallmark of the disease process.

Blood Pressure: 130/86 mmHg

Neither Disease Process Nor Medication Use:
This value is slightly elevated but not significantly enough to be directly attributed to asthma or medication. It could be situational due to stress or anxiety.

Oxygen Saturation: 88%

Disease Process:
The low oxygen saturation is indicative of hypoxemia caused by bronchoconstriction and impaired gas exchange during the asthma attack.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?

Correct Answer is C

Explanation

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

Explanation

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