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Exhibits

The nurse reviews the client's history of the presenting illness in the electronic medical record. Highlight the pieces of key subjective data which indicate the client is in need of health interventions.

A 34-year-old male client presents to the emergency department (ED) for an asthma attack that began after jogging through a local park. The client is able to answer questions every few words to catch his breath. He reports using his rescue inhaler three times, but he couldn't catch his breath. He reports that his symptoms are worse when outdoors and when exercising, and episodes like this make him extremely nervous. He says that it has been a couple of months since his last asthma attack, and he came to the ED today because he noticed his inhaler was expired and was worried the medication was not working.

A.

an asthma attack that began after jogging through a local park

B.

able to answer questions every few words to catch his breath

C.

reports using his rescue inhaler three times, but he couldn't catch his breath

D.

symptoms are worse when outdoors

E.

episodes like this make him extremely nervous

F.

came to the ED today because he noticed his inhaler was expired

Answer and Explanation

The Correct Answer is ["B","C","F"]

Rationale for correct answers:

  1. "The client is able to answer questions every few words to catch his breath."
    • Indicates severe shortness of breath, which requires immediate medical attention.
  2. "He reports using his rescue inhaler three times, but he couldn't catch his breath."
    • Demonstrates that his asthma attack is not responding to usual interventions, indicating the need for additional or advanced treatment.
  3. "He says that it has been a couple of months since his last asthma attack, and he came to the ED today because he noticed his inhaler was expired and was worried the medication was not working."
    • Highlights a lapse in medication management (expired inhaler), suggesting the need for health education and prescription renewal.

Rationale for incorrect answers:

  1. "Episodes like this make him extremely nervous."
    • While anxiety is relevant, it is a secondary issue compared to the physiological needs in this situation.
  2. "The client presents to the emergency department (ED) for an asthma attack that began after jogging through a local park."
    • The activity triggering the attack (jogging) is not an immediate factor needing intervention but rather an avoidable trigger to address long-term.
  3. "He reports that his symptoms are worse when outdoors and when exercising."
    • While important for identifying triggers, this is not an immediate priority for intervention in the emergency setting.


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Related Questions

Correct Answer is B

Explanation

Choice A reason: Activity intolerance related to ischemia is a common concern for clients with AMI, but it is not the primary nursing problem when the client is receiving thrombolytic therapy. The focus should be on monitoring for complications related to the therapy itself.

Choice B reason: Risk for injury related to effects of thrombolytics is the priority nursing problem for a client receiving thrombolytic therapy. Thrombolytics can cause serious bleeding complications, including internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse must closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.

Choice C reason: Ineffective breathing pattern related to adverse drug effects can occur following thrombolytic therapy, but it is not the primary concern. The risk of bleeding complications takes precedence as the priority nursing problem for this client.

Choice D reason: Deficient knowledge related to a new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period. Ensuring the client's safety by monitoring for bleeding complications is the primary focus.

Correct Answer is ["400"]

Explanation

Step-by-Step Calculation:

Step 1: Determine the total volume to be infused 100 mL

Step 2: Convert minutes to hours 15 minutes ÷ 60 minutes per hour = 0.25 hours

Step 3: Calculate the infusion rate in mL/hr 100 mL ÷ 0.25 hours = 400 mL/hr

Answer: 400 mL/hr

So, the nurse should program the infusion pump to deliver 400 mL/hr.

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