Patient Data

Exhibits

The nurse performs an initial focused assessment of the client.

Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.

Blood pressure 130/86 mmHg

Respirations 28 breaths/minute

Temperature 98.9" F (37.1°C)

Heart rate 112 beats/minute

Oxygen saturation 88% on room air

Answer and Explanation

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

In an asthmatic attack, exposure to triggers leads to bronchospasm which blocks airflow leading to impaired ventilation that manifests as respiratory distress- tachypnea. This prevents oxygenation with resultant hypoxia as evidenced by low SPO2 levels. Continuous use of a non- selective beta agonists leads to elevated heart rate.

Acute asthmatic attacks are not associated with changes in blood pressure

Acute asthmatic attacks are not associated with changes in temperature. However, when triggered by pulmonary infections, the client may experience episodes of fever.

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Correct Answer is B

Explanation

B. Thrombocytopenia, or low platelet count, increases the risk of spontaneous bleeding, which can manifest as occult blood in the urine or stool. Regular monitoring allows for early detection of bleeding complications, prompting timely intervention and preventing further complications.
A. While using a large gauge IV catheter may be appropriate to minimize trauma and bleeding risk during blood sampling in a client with thrombocytopenia, it is not the highest priority intervention.
C. Removing cold and frozen foods from dietary trays may be advised in clients with thrombocytopenia to minimize the risk of cold-induced platelet aggregation and potential vascular occlusion, known as cold agglutinin disease. However, this intervention is not directly related to preventing bleeding complications associated with thrombocytopenia.
D. Wrapping bruised areas with elastic bandage dressings may provide support and protection but is not the most appropriate intervention for managing thrombocytopenia-related bleeding complications.

A. Lung sounds clear B. Client can now speak in full sentences without pausing C. Respirations 16 breaths/minute D. Client reports, "It's a lot easier to breathe now." E. Blood Pressure 122/84 mmHg

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

Explanation

Short-acting beta agonists (SABAs) are a type of bronchodilator medication commonly used to relieve the symptoms of an asthmatic attack. When inhaled, SABAs act quickly to relax the smooth muscles in the airways, which helps to open up the air passages and improve airflow to the lungs. This rapid bronchodilation can alleviate symptoms such as wheezing, coughing, chest tightness, and shortness of breath, providing immediate relief during an asthma exacerbation.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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

Explanation

Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

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 presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?

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