Patient Data.
Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
The rationale for selecting impaired gas exchange is based on the clinical manifestations presented by the client. The client's difficulty in breathing, the need to pause to catch breath, the ineffectiveness of the rescue inhaler, and the expressed feeling of nervousness during episodes are indicative of a compromised gas exchange. This is further supported by the objective data: an oxygen saturation of 88% on room air is below normal levels, suggesting that the client is not receiving adequate oxygen. Expiratory wheezes indicate an obstruction of airflow, commonly seen in asthma attacks, which can impair gas exchange. Therefore, the nurse's assessment and the client's symptoms align with the diagnosis of impaired gas exchange, necessitating immediate intervention to improve the client's respiratory function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assessing the pin sites for signs of infection is essential in clients with skeletal traction to detect any early signs of infection, such as redness, swelling, warmth, or purulent drainage. Prompt identification and management of pin site infections can prevent complications.
B. Administering pain medication at designated intervals around the clock helps to ensure adequate pain control and comfort for the client. However, this intervention alone does not specifically address the care needs related to skeletal traction.
C. Assessing the pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this assessment is not directly related to the care of skeletal traction itself.
D. Removing traction every shift is not indicated unless there is a specific reason to do so as ordered by the healthcare provider. Continuous traction is often necessary for proper alignment and stabilization of the fracture. Additionally, providing skin care is important to prevent skin breakdown around the traction device, but removing traction every shift is not part of routine care.
Correct Answer is ["A","B","C","F"]
Explanation
A. Client education is also important, focusing on asthma management, the importance of carrying a non-expired inhaler, and avoiding known triggers.
B. Oxygen therapy via nasal cannula should be considered due to the patient's oxygen saturation of 88% on room air, aiming to maintain SpO2 above 94%.
C. Requesting a list of current medications is essential for reviewing potential drug interactions and ensuring comprehensive care.
D. Trendelenburg position is not indicated for this condition and could exacerbate breathing difficulties.
E. While the patient's condition should be closely monitored, the current information does not suggest an immediate need for intubation; however, the healthcare provider should be notified if the patient's condition worsens.
F. Administering medications as ordered is crucial to address the immediate respiratory distress.
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