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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Free Nursing Study Resources

Correct Answer is B

Explanation

B Early signs of rheumatoid arthritis often manifest in the small joints of the hands and fingers. Common findings may include swelling, redness, warmth, and stiffness in these joints. Therefore, observing the client's fingers for any signs of inflammation or deformity can provide valuable clues for early detection of rheumatoid arthritis.

A Swollen lymph node may occur in certain types of arthritis, such as reactive arthritis but they are not typically a hallmark sign of rheumatoid arthritis.

C Rheumatoid nodules can develop in later stages of rheumatoid arthritis, but they are not typically present in the early stages of the disease.

D Rheumatoid arthritis is an autoimmune disease that can affect multiple organ systems, including the skin but characteristic skin lesions are not typically associated with the early stages of the condition.

A. Review with the client the need to avoid foods that are rich in milk and cream. B. Reinforce the teaching by asking the client to make a list of snack foods high in dairy content. C. Remind the client that it is also important to switch to decaffeinated coffee and tea. D. Suggest that the client also plan to eat frequent small meals to reduce discomfort.

Correct Answer is A

Explanation

A. Consuming dairy products, especially those rich in milk and cream, can stimulate gastric acid secretion and exacerbate symptoms of a duodenal ulcer. Therefore, it is essential for the nurse to review with the client the importance of avoiding foods that can aggravate the ulcer and worsen symptoms.

B. While reinforcing teaching about dietary modifications is important, encouraging the client to make a list of snack foods high in dairy content would not address the issue of avoiding dairy products to protect the duodenal ulcer.

C. While switching to decaffeinated coffee and tea can be beneficial for individuals with duodenal ulcers, it does not directly address the client's misconception about using dairy products to coat and protect the ulcer.

D. Eating frequent small meals can help reduce discomfort associated with duodenal ulcers by minimizing gastric acid secretion and preventing large fluctuations in stomach volume.

However, this option does not address the client's misconception.

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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

Patient Data Exhibits Which technique should the nurse use when assessing the client for early signs of rheumatoid arthritis?

Correct Answer is B

Explanation

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow- up action by the nurse?

Correct Answer is A

Explanation

The nurse is discussing dietary choices with a client who is newly diagnosed with celiac disease. Which menu choice by the client indicates a need for further teaching?

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

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

A client with emphysema reports difficulty breathing and exhibits audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants Immediate intervention by the nurse?

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?

A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

Patient Data

Exhibits

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