Try Naxlex NCLEX-RN (Free-Trial)

Patient Data

Click to highlight the assessment findings that require immediate follow up by the nurse.

Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.

She has mild subcostal retractions and is sitting in an upright position.

Wheezes are noted throughout the lung fields.

client is pale.

She has strong peripheral pulses that are equal bilaterally.

heart rate is 122 beats/minute

oxygen saturation 91% on room air.

Answer and Explanation

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

Brief introduction:

Asthma is a chronic inflammatory airway disorder characterized by reversible bronchial hyperresponsiveness and airway narrowing. During an acute exacerbation, the clinical presentation reflects the body’s struggle to maintain adequate ventilation and oxygenation. When a client presents with symptoms that do not respond to initial rescue inhalers (albuterol), it indicates a potentially life-threatening event, such as status asthmaticus, requiring aggressive intervention to prevent respiratory failure.

Rationale for correct answers:

She has mild subcostal retractions and is sitting in an upright position: Retractions indicate the use of accessory muscles to breathe, signaling significant respiratory distress. Sitting upright (often in a tripod position) is a compensatory mechanism to maximize lung expansion and ease the work of breathing.
Wheezes are noted throughout the lung fields: High-pitched whistling sounds indicate significant airway narrowing and turbulence. While wheezing is expected in asthma, the fact that it is present throughout the lung fields after multiple doses of albuterol indicates the treatment has not yet resolved the obstruction.
The client is pale: Pallor in an acute respiratory context can be a sign of poor peripheral perfusion or early hypoxia. It suggests that the respiratory distress is beginning to have a systemic impact.
Her heart rate is 122 beats/minute: Tachycardia in this client is likely due to two factors: the physiological stress of hypoxia/distress and a known side effect of the multiple doses of albuterol (a beta-agonist) she received. This requires monitoring to ensure the heart rate stabilizes as the respiratory status improves.
Oxygen saturation 91% on room air: This is below the target range (typically >94% for most patients, or >92% in some protocols). A saturation of 91% indicates mild to moderate hypoxemia and necessitates the immediate administration of supplemental oxygen.

Rationale for incorrect answer:

She has strong peripheral pulses that are equal bilaterally: This is a normal/reassuring finding. It indicates that despite the respiratory distress, the client's circulatory volume and peripheral perfusion (aside from the noted pallor) remain intact for the moment.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) involves excessive ADH release, causing profound water retention and dilutional hyponatremia. As serum sodium levels drop below 120 mEq/L, water moves osmotically into the intracellular space, leading to cerebral edema. This increased intracranial pressure destabilizes neuronal membranes, significantly raising the risk of generalized seizures and permanent neurological damage.

Rationale:

A. Administering hypertonic IV fluids is a high-risk pharmacological intervention used to correct severe hyponatremia. While it helps shift fluid out of the brain cells, it must be performed with extreme caution to avoid osmotic demyelination syndrome. While critical for treatment, it is a medical prescription rather than a primary nursing safety precaution.

B. Limiting oral water intake is a foundational treatment to prevent further dilutional effects. Restricting fluids helps stabilize sodium levels but does not provide an immediate protective barrier against the acute physical injuries associated with neurological irritability. The nurse must prioritize physical safety measures while the fluid restriction gradually takes effect.

C. Initiating seizure precautions is the most important intervention for injury prevention. Severe hyponatremia causes brain swelling, which can trigger sudden, violent tonic-clonic seizures. Implementing padded side rails and having suction equipment available ensures the client is protected from physical trauma and aspiration during a sudden neurological event.

D. Assessing neurological status every 8 hours is a necessary component of monitoring clinical progression. However, an 8-hour interval is far too infrequent for a client with acute hyponatremia who is at risk for rapid deterioration. More frequent assessments are required, but monitoring alone does not physically protect the client from injury if a seizure occurs.

A. Encourage the client to have lunch off the unit. B. Complete an assessment of social support. C. Give the client a schedule of planned daily activities. D. Engage the client in a game of cards.

Correct Answer is D

Explanation

Brief introduction:

Schizophrenia is a complex neurobiological disorder characterized by positive symptoms, such as hallucinations, and negative symptoms, including asociality and diminished emotional expression. Social withdrawal and poor interpersonal functioning result from neurocognitive deficits and a profound lack of intrinsic motivation. Effective psychiatric nursing interventions focus on providing structured social interactions that reduce isolation while minimizing the cognitive and emotional demand on the client during periods of acute withdrawal.

Rationale:

A. Encouraging a client to leave the unit for lunch introduces an overwhelming amount of environmental stimuli and social pressure. This can exacerbate symptoms of paranoia or sensory overload, causing the client to retreat further into isolation. Safe interventions must occur within the controlled environment of the psychiatric unit to ensure the client's stability.

B. While assessing social support is a necessary component of the overall nursing process, it is not a direct intervention to address the current problem of social withdrawal. Data collection does not solve the immediate need for peer or staff engagement. The nurse must prioritize active participation over purely diagnostic activities during the shift.

C. Providing a schedule is a supportive measure for orientation, but it does not actively bridge the gap of social alienation. A list of activities remains a passive tool that a withdrawn client is likely to ignore without direct facilitation from the staff. Structure is useful, but it lacks the interpersonal component required to improve social functioning.

D. Engaging the client in a card game provides a low-pressure activity that facilitates social interaction without requiring intense verbal communication. Activities focused on a third object, like a game, decrease the threat of intimacy and allow the client to practice social skills in a non-threatening manner. This is the most effective way to stimulate cognitive engagement and rapport.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury?

Correct Answer is C

Explanation

A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?

Correct Answer is D

Explanation

Patient Data Drag from Word Choices to complete the sentence. This client requires more protein than the average adult due to her dropdown and dropdown

To auscultate for a carotid bruit, the nurse places the stethoscope at which location (Select the correct location on the image. To change, click on a new location.)

Patient Data After the nurse assesses the client, the healthcare provider (HCP) writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

A staff nurse approaches the lead nurse to request an assignment change. The staff nurse reports difficulty caring for a certain client who is often angry and believes he has communicated needs that have not been met by the nurse. Which action by the lead nurse best exemplifies leadership?

Following a cardiac catheterization, an adult client is sent to the cardiovascular unit. The nurse instructs the client to keep the affected leg immobile. Which intervention should the nurse plan to include in this client's plan of care?

Patient Data Review H and P, nurse's notes, and flow sheet. The client informs that she is not a vegetarian, but she does not care for red meat or chicken. Which food(s) can the nurse recommend to enhance protein intake? Select all that apply.

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal. Which action should the nurse implement?

The lead nurse is considering a change in staff scheduling methods to increase continuity of care. Which scheduling/staffing type best promotes continuity of care?