Patient Data

Exhibits

Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings

Rhonchi in the right lung

Symmetric chest expansion

Oxygen saturation greater than 949%

PaCO2 55 mm Hg on a blood gas

Client ambulates without shortness of breath

Diminished breath sounds in the right lung

Answer and Explanation

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

A. Rhonchi are abnormal breath sounds that indicate the presence of mucus or fluid in the airways. Finding rhonchi in the right lung suggests the presence of respiratory congestion or obstruction, which may indicate ineffective treatment or ongoing respiratory issues.

B. Symmetric chest expansion indicates equal and adequate movement of both sides of the chest during inhalation. This finding suggests that there are no restrictions or abnormalities in the chest wall or lung tissue, which is indicative of effective treatment.

C. Oxygen saturation greater than 94% indicates adequate oxygenation of the blood, which is a positive indicator of effective treatment, particularly in clients with respiratory issues such as pneumonia or COPD.

D. A PaCO2 level of 55 mm Hg indicates hypercapnia, which is an elevated level of carbon dioxide in the blood. This finding suggests inadequate ventilation or respiratory failure, indicating ineffective treatment.

E. The ability to ambulate without experiencing shortness of breath suggests improved respiratory function and effective treatment, as it indicates adequate oxygenation and ventilation.

F. Diminished breath sounds suggest reduced airflow or lung volume in the affected area. This finding may indicate ongoing respiratory issues or incomplete resolution of the condition, suggesting ineffective treatment.

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Correct Answer is A

Explanation

A. Inserting a nasogastric tube (NGT) and attaching it to low intermittent suction would be appropriate in this situation. Dark brown emesis could indicate gastrointestinal bleeding, which may require gastric decompression to prevent further vomiting and assess the volume and characteristics of the gastric contents.

B. Placing an indwelling urinary catheter and attaching a bedside drainage unit is not the priority intervention in this scenario.

C. Sending the client to x-ray for a flat plate of the abdomen may provide diagnostic information, but it is not the most immediate intervention needed in this situation.

D. Giving a prescribed analgesic for a temperature above 101°F (38.3°C) is not the priority intervention in this scenario.

A. Primes the inhaler with 7 pumps. B. Rinses the mouth after each use. C. Stores the medication at room temperature. D. Attaches spacer device to the Inhaler.

Correct Answer is A

Explanation

A. According to the usage guidelines for ipratropium inhalers, priming the inhaler typically requires only two sprays into the air, away from the face, before the first use to ensure proper medication dosage.

B. Rinsing the mouth after each use is a recommended practice to prevent irritation and infection.

C. Storing the medication at room temperature is correct, as extreme temperatures can affect the medication's efficacy.

D. Attaching a spacer device to the inhaler is also a recommended practice to improve medication delivery and reduce the risk of side effects.

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Patient Data Exhibits Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

Correct Answer is A

Explanation

Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

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Patient Data

Exhibits

Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings