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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.

an asthma attack that began after jogging through a local park

able to answer questions every few words to catch his breath

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

symptoms are worse when outdoors

episodes like this make him extremely nervous

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:

"The client is able to answer questions every few words to catch his breath."
- Indicates severe shortness of breath, which requires immediate medical attention.
"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.
"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:

"Episodes like this make him extremely nervous."
- While anxiety is relevant, it is a secondary issue compared to the physiological needs in this situation.
"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.
"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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Correct Answer is A

Explanation

Choice A reason: Continuous cardiac monitoring is crucial for a client who has suffered an electrical injury. Electrical injuries can cause arrhythmias and other cardiac complications, which may not be immediately apparent. Continuous monitoring allows for the early detection and treatment of any cardiac abnormalities, which is vital for the patient's safety and recovery.

Choice B reason: Evaluating the level of consciousness is important for any patient, especially those with significant injuries, but it is not the most critical intervention in this scenario. While neurological assessments are part of comprehensive care, the immediate risk posed by cardiac complications from the electrical injury takes precedence.

Choice C reason: Performing passive range of motion exercises is beneficial for preventing contractures and maintaining joint mobility in immobile patients. However, it is not the most urgent intervention in the context of an electrical injury, where cardiac monitoring is paramount.

Choice D reason: Assessing lung sounds every 4 hours is a valuable part of monitoring for respiratory complications, particularly in burn patients. However, the immediate cardiac risks associated with electrical injuries necessitate continuous cardiac monitoring as the priority intervention.

A. Take the client to the emergency department (ED) B. Apply the client's home oxygen C. Ensure that the client avoids salt intake for the rest of the day D. Check for a thrill and bruit at the client's dialysis access site

Correct Answer is A

Explanation

Choice A reason: Taking the client to the emergency department is crucial because missing a dialysis session can lead to severe complications such as fluid overload, high potassium levels, and other electrolyte imbalances. These conditions can be life-threatening and require immediate medical attention to stabilize the client.

Choice B reason: Applying home oxygen is not the most critical intervention in this scenario. While oxygen therapy might be necessary in some cases, it does not address the immediate risk of complications arising from missed dialysis.

Choice C reason: Ensuring that the client avoids salt intake for the rest of the day is important for managing fluid balance, but it is not the most urgent action needed in this situation. The client's lethargy and difficulty arousing indicate a more serious underlying issue that requires immediate medical evaluation.

Choice D reason: Checking for a thrill and bruit at the client's dialysis access site is important for assessing the patency of the access site, but it is not the most critical action in this scenario. The immediate concern is the client's lethargy and potential complications from missed dialysis, which necessitate emergency medical care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care?

Correct Answer is A

Explanation

A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?

Correct Answer is A

Explanation

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?

A client who works at a computer most of the working day comes to the clinic reporting pain in both hands that causes the client to wake during the night. Which action should the nurse implement to assess for carpal tunnel syndrome?

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing fluid intake, the nurse should include which type of fluid limitation?

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

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.