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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Teaching the importance of medication regimen and follow-up protocol is crucial for treating gonorrhea and preventing its spread to others. It addresses the immediate health concern and helps prevent further transmission.

B. While partners without symptoms may not show signs of infection, they could still be carriers of gonorrhea and should be tested and treated if necessary.

C. While using safe sex practices can reduce the risk of STIs, it may not completely eliminate the risk, especially if a partner has multiple sexual partners.

D. While sexual intercourse is a common mode of transmission for STIs, not all STIs are transmitted exclusively through sexual intercourse.

A. Have the antifungal creams been effective? B. Do your family members share combs and brushes? C. Do you have any dry patches on your feet and hands? D. Has everyone at home already had varicella?

Correct Answer is D

Explanation

A. Asking about the effectiveness of antifungal creams is not relevant to herpes zoster, which is caused by the varicella-zoster virus.

B. Inquiring about family members sharing combs and brushes is not directly related to herpes zoster, as it is not transmitted through sharing personal items.

C. Asking about dry patches on the feet and hands may provide information about other dermatological conditions but does not specifically address herpes zoster.

D. Asking whether everyone at home has already had varicella is important because herpes zoster, commonly known as shingles, is caused by reactivation of the

varicella-zoster virus, which also causes chickenpox (varicella). Individuals who have not had chickenpox or been vaccinated against it may be at risk of developing chickenpox if exposed to herpes zoster lesions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

Correct Answer is A

Explanation

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

Correct Answer is D

Explanation

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places It over the wound. Which intervention should the nurse implement next?

A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only)

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?

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

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 bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?