Patient Data

Exhibits

The nurse has implemented additional needed actions.

Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one, but may have more than one answer selected.

Assessment Data: Indicates the Interventions Were Successful/ No Indication that the Interventions Were Successful

Heart Rate 105 beats/minute

Client can now speak in full sentences without pausing.

Lung sounds clear

Respirations 16 breaths/minute

Client reports, “It’s a lot easier to breathe now.”

Blood Pressure 122/84 mmHg

Answer and Explanation

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

Correct Answers:

Indicates the Interventions Were Successful: A, B, C, D, E, F

No Indication that the Interventions Were Successful: None

Rationale:

The assessment data provided indicates a positive response to the interventions for the asthma attack. The decrease in heart rate from 112 to 105 beats per minute, alongside the client's ability to speak in full sentences without pausing, suggests an improvement in respiratory function. Clear lung sounds and a reduction in respiratory rate to 16 breaths per minute further support this conclusion. The client's subjective report of eased breathing and the maintenance of blood pressure within normal limits post-intervention are also indicative of successful treatment. These observations collectively demonstrate the effectiveness of the administered medications and oxygen therapy in managing the acute asthma symptoms presented by the client.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Muscle atrophy may indicate various underlying conditions but is not typically associated with an exacerbation of SLE. While it should be noted, it is not the most critical finding to report in this context.

B. Low-grade fever is a common symptom of SLE exacerbation and may not require immediate reporting unless accompanied by other concerning symptoms.

C. Joint pain is a hallmark symptom of SLE exacerbation but may not warrant immediate reporting unless it is severe or debilitating.

D. Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.

A. Alternate IV and IM analgesic medications. B. Administer opioid and non-opioid medication simultaneously. C. Give maximum dosage when score reaches 10. D. Educate client on signs and symptoms of narcotic dependency.

Correct Answer is B

Explanation

A. Alternating IV and IM analgesic medications may be appropriate for pain management in some situations but is not the best initial intervention for continuous, severe pain in a client with stage IV bone cancer.

B. Administering opioid and non-opioid medication simultaneously is an appropriate intervention for managing severe pain, as it addresses pain from multiple pathways and may provide more effective pain relief.

C. Giving maximum dosage when the pain score reaches 10 is not recommended, as it may lead to overmedication and increased risk of adverse effects. Pain management should be based on the client's reported pain intensity and individualized needs.

D. Educating the client on signs and symptoms of narcotic dependency is important but is not the priority intervention in this situation. Pain management and relief should be the immediate focus for the client's comfort and quality of life.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?

Correct Answer is D

Explanation

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

Patient Data. Exhibits Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize dropdown as the priority problem for this client, as evidenced by the client's statement, dropdown.

While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?