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,B,C,D

Explanation

A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.

This client has the highest priority, as he or she may be experiencing an acute asthma atack that can compromise the airway and oxygenation. The PN should assess the client's respiratory status, administer bronchodilators, and monitor for improvement or deterioration.

A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.

This client has the second highest priority, as he or she may be experiencing hypoglycemia, which is a low blood glucose level that can cause neurologic symptoms such as confusion, seizures, or coma. The PN should check the client's blood glucose level, provide a source of glucose, and monitor for recovery or complications.

A 10-year-old child with bleeding lacerations on both knees after falling on the playground.

This client has the third highest priority, as he or she may have a risk of infection or blood loss from the wounds. The PN should clean and dress the lacerations, apply pressure if needed, and check for signs of infection or inﬂammation.

A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

This client has the lowest priority, as he or she does not have a life-threatening or urgent condition, but a psychosocial or emotional issue. The PN should provide comfort and reassurance to the child, change his or her clothes, and explore the possible causes of the incontinence.

A. Visible swelling of the neck, with no pain. B. Warm, soft, moist, salmon colored skin. C. Central type obesity, with thin extremities. D. Husky voice and troubled by hoarseness.

Correct Answer is C

Explanation

C. Cushing's syndrome often leads to central (truncal) obesity, characterized by fat accumulation around the abdomen and face, while the extremities may appear relatively thin due to muscle wasting. This distribution of fat and muscle wasting contributes to the characteristic "moon face" appearance seen in individuals with Cushing's syndrome.

A. Visible swelling of the neck with no pain is not typically associated with Cushing's syndrome. Swelling of the neck may be indicative of other conditions such as goiter or thyroid nodules.
B. Warm, soft, moist, salmon-colored skin is not typically associated with Cushing's syndrome. Instead, individuals with Cushing's syndrome may exhibit thin, fragile, and easily bruised skin due to the effects of cortisol on collagen synthesis and skin integrity.
D. Husky voice and hoarseness are not typically associated with Cushing's syndrome. These symptoms may be indicative of vocal cord dysfunction or other conditions affecting the larynx or vocal cords.

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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,B,C,D

Explanation

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

Correct Answer is C

Explanation

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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?

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.