Exhibits

The nurse has implemented additional needed actions. Indicate the assessment data which indicate the interventions were successful and which assessment data provide no indication that the interventions were successful. Each column must have at least one answer selected.

Client can now speak in full sentences without pausing

Respirations: 16 breaths per minute.

Blood pressure: 122/84 mmHg.

Client reports “It’s a lot easier to breathe now.”

Heart rate 105 beats/minute

Lung sounds clear

Answer and Explanation

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

Choice A reason: The client can now speak in full sentences without pausing, which indicates that the interventions were successful. This improvement suggests that the client's airways are less obstructed and he is able to breathe more easily. The ability to speak in full sentences is a key indicator of improved respiratory function and is often used as a measure of asthma control.

Choice B reason: Respirations at 16 breaths per minute indicate a successful intervention. This is within the normal range for adults and suggests that the client's breathing has stabilized. Before the intervention, the client’s respiratory rate was 28 breaths per minute, which is elevated and indicative of respiratory distress.

Choice C reason: Blood pressure at 122/84 mmHg does not indicate the success of the interventions. Blood pressure can be influenced by many factors and may not directly correlate with respiratory improvements. While the patient's blood pressure has decreased slightly, this change is not a definitive indicator of successful asthma treatment.

Choice D reason: The client reporting, "It’s a lot easier to breathe now," indicates successful interventions. This subjective report aligns with the clinical improvements observed in the client’s breathing and overall respiratory function. The client's perception of relief is an important aspect of assessing treatment efficacy.

Choice E reason: Heart rate at 105 beats per minute does not indicate the success of the interventions. Although the heart rate has decreased from 116 to 105 beats per minute, it is still elevated and may not directly reflect the improvement in respiratory status. Elevated heart rate could be due to anxiety or other factors unrelated to asthma management.

Choice F reason: Lung sounds being clear indicates successful interventions. Clear lung sounds suggest that the bronchospasm and airway obstruction have been relieved, which is a positive outcome of the administered medications and oxygen therapy. This objective finding is a strong indicator of improved respiratory function.

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Correct Answer is B

Explanation

Choice A reason: Checking the blood pressure every five minutes for one hour is important, especially if the blood pressure is unstable. However, this action does not address the immediate issue of the client’s low temperature, which needs to be verified and addressed promptly to prevent complications such as hypothermia.

Choice B reason: Taking the client's temperature using another method is crucial. The extremely low tympanic temperature reading may not be accurate, and confirming the client's core body temperature is essential. Hypothermia can lead to serious complications, including altered cardiovascular and respiratory function, and needs to be managed promptly.

Choice C reason: Raising the head of the bed to 60 to 90 degrees is not appropriate in this situation. Elevating the head of the bed is typically done to improve respiratory function or decrease intracranial pressure, but it does not address the potential issue of hypothermia indicated by the low temperature reading.

Choice D reason: Asking the client to cough and deep breathe is a good practice to prevent postoperative complications such as atelectasis, but it is not the priority intervention in this scenario. The immediate concern is verifying the client's temperature to rule out or address hypothermia.

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

Explanation

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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Exhibits The nurse has implemented additional needed actions. Indicate the assessment data which indicate the interventions were successful and which assessment data provide no indication that the interventions were successful. Each column must have at least one answer selected.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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

Explanation

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Exhibits

The nurse has implemented additional needed actions. Indicate the assessment data which indicate the interventions were successful and which assessment data provide no indication that the interventions were successful. Each column must have at least one answer selected.