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.

Nursing Test Bank

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Correct Answer is C

Explanation

C. Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. Anemia, characterized by low hemoglobin levels, can lead to symptoms such as fatigue, weakness, and pale appearance. Diclofenac, like other nonsteroidal anti-inflammatory drugs (NSAIDs), can cause gastrointestinal bleeding, which may result in iron deficiency anemia.

A. While abnormality in sodium levels can occur and may contribute to symptoms such as fatigue, pale appearance, and weakness, sodium levels are not typically affected directly by diclofenac use or rheumatoid arthritis.

B. Low total protein levels can contribute to symptoms such as fatigue and weakness. However, total protein levels may not be directly affected by diclofenac use or rheumatoid arthritis.

D. Assessing glucose levels is not be the most relevant laboratory value to review in this situation.

A. Identify effective pain relief measures. B. Provide a numeric pain scale. C. Ask the client to describe the pain. D. Observe body language and movement.

Correct Answer is C

Explanation

C. Asking the client to describe their pain allows the nurse to gather subjective information directly from the client, which can provide valuable insight into the quality, intensity, location, and duration of the pain.

A. This option focuses on pain management rather than pain assessment. While identifying effective pain relief measures is important, it does not directly address the need to assess the quality of the client's pain.

B. While numeric pain scales can be useful for quantifying pain intensity, they do not capture the quality or characteristics of the pain.

D. Observing body language and movement can provide valuable information about the client's pain experience, such as grimacing, guarding, or difficulty moving. However, this approach primarily assesses pain behaviors rather than the quality of the pain itself.

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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

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client's serum laboratory values is most important for the nurse to review?

Correct Answer is C

Explanation

To assess the quality of an adult client's pain, which approach should the nurse use?

Correct Answer is C

Explanation

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

An adult client is admitted with AIDS and oral Candide albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection. Prior to administering the H. pylori treatment regimen, the nurse should review the electronic medical record for which medication?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

A client receives a prescription for vancomycin 500 mg IV every 8 hours. The medication is provided in "500 mg per 100 mL of dextrose 5% in water." To administer the medication over an hour, the nurse should set the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

Patient Data

Exhibits

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