Patient Data

Exhibits

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen.

Which action(s) should the nurse take next? Select all that apply.

Administer additional nebulizer treatment as ordered.

Take and monitor vital signs.

Apply a nonrebreather oxygen mask.

Increase oxygen flow.

Raise the head of the bed.

Provide client incentive spirometer and instruct on use.

Answer and Explanation

Correct Answer : A,B,D,E

Inhaled short acting beta agonists can should be administered up to 3 times until there the obstruction in managed. In the event that the nebulization fails to relieve the respiratory distress, other treatment options such as magnesium sulphate can be used.

Oxygen flow should also be titrated appropriately to achieve the targeted SPO2 levels. However, changing the modality of oxygen delivery is not necessary at this part.

Continuous vital signs monitoring allows for timely interventions at all times to prevent respiratory failure. Although not a primary measure, raising the head of the bed can increase comfort reducing the work of breathing.

While incentive spirometry may have a role in the management of asthma in certain situations, such as during the recovery phase after an acute exacerbation or in individuals with chronic asthma who have reduced lung function, it is not typically used as a primary intervention during the acute phase of an asthma attack.

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Correct Answer is A

Explanation

A. The client is receiving heparin sodium, an anticoagulant medication, which increases the risk of bleeding during surgery, especially in combination with the open fracture and ongoing bleeding. The healthcare provider needs to be informed of the client's medication history to determine the appropriate management of anticoagulation therapy perioperatively.
B. While obtaining informed consent for surgery and potential blood transfusion is important, it is not the priority in this situation.
C. Monitoring the injection sites for signs of bruising is important for assessing for complications related to heparin administration, such as hematoma formation or bleeding. However, in the context of a client with an open fracture and moderate bleeding, the priority is to address the potential interaction between heparin therapy and the risk of bleeding from the fracture site.
D. While it is important to provide education to the client about the potential risks and complications associated with surgery, including bleeding, this is not the priority nursing action in this situation.

A. Uneven hair distribution. B. Lower leg edema. C. Bronze pigmentation. D. Bounding peripheral pulse.

Correct Answer is A

Explanation

A. Compromised peripheral arterial circulation can lead to decreased blood flow to the extremities, resulting in poor tissue perfusion. Over time, this can cause changes in the skin and hair distribution. Uneven hair distribution, or sparse hair growth, is a characteristic finding in areas of reduced arterial circulation due to inadequate oxygen and nutrient delivery to the hair follicles.

B. Lower leg edema is more commonly associated with compromised venous circulation rather than arterial circulation. It occurs due to impaired venous return, leading to fluid accumulation in the tissues.
C. Bronze pigmentation of the skin is not typically associated with compromised peripheral arterial circulation. Bronze pigmentation can occur in conditions such as hemochromatosis or Addison's disease but is not a specific sign of peripheral arterial disease.

D. In peripheral arterial disease, peripheral pulses may be diminished or absent due to arterial narrowing or occlusion. Bounding peripheral pulses are more commonly associated with conditions such as arterial hypertension.

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Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

Correct Answer is A

Explanation

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which Instruction regarding skin care of the portal site should the nurse provide?

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 college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

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

A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?

Patient Data

Exhibits

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen.

Which action(s) should the nurse take next? Select all that apply.