Patient DataThe nurse has Implemented additional needed actions.

Exhibits

Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one, but may have more than one answer selected.

Lung sounds clear

Client can now speak in full sentences without pausing

Respirations 16 breaths/minute

Client reports, "It's a lot easier to breathe now."

Blood Pressure 122/84 mmHg

Answer and Explanation

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

Short-acting beta agonists (SABAs) are a type of bronchodilator medication commonly used to relieve the symptoms of an asthmatic attack. When inhaled, SABAs act quickly to relax the smooth muscles in the airways, which helps to open up the air passages and improve airflow to the lungs. This rapid bronchodilation can alleviate symptoms such as wheezing, coughing, chest tightness, and shortness of breath, providing immediate relief during an asthma exacerbation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

C. Risk for aspiration related to vomiting.Nausea and vomiting increase the risk of aspiration because the vomitus can enter the airway if the client is unable to protect their airway effectively. Therefore, it is critical for the nurse to prioritize interventions aimed at reducing the risk of aspiration, such as maintaining the client in a side-lying position and providing suctioning equipment as needed.
A. While renal function impairment is a potential complication of kidney stones, it is not the most immediate concern in this scenario. The client's severe right flank pain, nausea, and vomiting indicate an acute episode of renal colic, where the kidney stone obstructs the urinary tract, causing intense pain and urinary stasis. While impaired renal function is a concern, it is secondary to the immediate risk of aspiration.
B. Acute pain related to the renal calculus is a significant concern for the client and requires prompt intervention to alleviate discomfort. However, in this scenario, the risk of aspiration from vomiting takes precedence over pain management because aspiration poses an immediate threat to the client's respiratory status.
D. While nutritional deficit related to nausea is a valid concern, it is not the highest priority nursing problem in this scenario. The client's nausea and vomiting are acute symptoms requiring immediate attention to prevent complications such as aspiration. Once the risk of aspiration is addressed, nutritional support and interventions to manage nausea can be implemented.

A. Joint pain. B. Hematuria. C. Muscle atrophy. D. Low grade fever.

Correct Answer is B

Explanation

B. Hematuria can indicate renal involvement, which is a serious complication of SLE. Lupus nephritis, inflammation of the kidneys caused by SLE, can lead to hematuria, proteinuria, and impaired kidney function. Monitoring for renal complications is essential in managing SLE exacerbations, and hematuria warrants immediate attention to assess the extent of renal involvement and adjust treatment as necessary.
A. Joint pain is a common symptom of systemic lupus erythematosus (SLE), an autoimmune disease that can affect multiple organs and tissues, including the joints. While joint pain can be distressing for the patient, it is not necessarily an urgent or life-threatening complication requiring immediate intervention.
C. Muscle atrophy, or the wasting away of muscle tissue, can occur in individuals with systemic lupus erythematosus (SLE), particularly if they are experiencing prolonged periods of inactivity due to joint pain, fatigue, or other symptoms. While muscle atrophy can contribute to functional impairment and decreased quality of life, it is not typically considered an urgent or life-threatening complication requiring immediate intervention.
D. Low-grade fever is a common symptom in systemic lupus erythematosus (SLE), often occurring during disease flares or exacerbations. Monitoring the patient's temperature and assessing for other signs of infection or disease activity is important, but low-grade fever alone may not warrant urgent intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

Correct Answer is C

Explanation

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?

Correct Answer is B

Explanation

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?

Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)