Patient Data

Exhibits

The nurse has identified the priority problem for the client and now must determine proper care interventions.

Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

Administer medications as ordered.

Provide client teaching.

Place the client in Trendelenburg position

Ask the client for a list of current medications.

Notify the healthcare provider of the client's need for intubation

Apply oxygen via nasal cannula

Answer and Explanation

Correct Answer : A,B,D,F

A The use of short acting beta agonists and oral steroids is key during an asthmatic attack to prevent respiratory failure.
D The nurse should also rule out the use of medications such as beta blockers which may predispose to asthmatic attack due to bronchospasms.
F Oxygen therapy should be initiated to prevent hypoxemia due to impaired ventilation. At this point, intubation may not be necessary until first line interventions have been attempted.
B Client teaching on proper inhalation technique is key. The client should also be advised on avoidance of triggers to prevent recurrence of the asthmatic attack. This, however, should be done after the client is stabilized.

Incorrect;

The Trendelenburg position is not recommended. Instead, sitting upright or in a semi-upright position can help expand the chest and improve lung expansion. This position allows the diaphragm to move more freely and can facilitate easier breathing. Leaning forward slightly may also help reduce the feeling of chest tightness.

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Correct Answer is D

Explanation

D. In a client presenting with urinary symptoms and lower back pain, measuring the temperature and pulse rate is essential for assessing for signs of systemic infection, such as fever (elevated temperature) and tachycardia (elevated pulse rate). These vital signs can help determine the urgency of the situation and guide further assessment and management.
A. Palpating the right flank for tenderness may be appropriate to assess for signs of kidney involvement, such as in pyelonephritis. However, this intervention is not the first priority. Assessing for systemic signs of infection, such as fever, is more urgent.
B. Evaluating the urine for a strong odor may provide additional information about the student's symptoms, but it is not the first intervention priority.

C. Testing the urine for the presence of hematuria (blood in the urine) is an important diagnostic step in evaluating urinary symptoms, but it is not the first intervention priority. Hematuria may be present in various conditions, including UTIs, kidney stones, or other urinary tract disorders.

A. Notify the healthcare provider as soon as possible. B. Wear braces on both wrists during the night. C. Elevate the hands on two pillows at night. D. Apply cold compresses for 30 minutes before bedtime.

Correct Answer is B

Explanation

B. Wearing wrist braces or splints at night can help alleviate symptoms of carpal tunnel syndrome by keeping the wrists in a neutral position and reducing pressure on the median nerve. This can help decrease pain and tingling sensations that often worsen at night due to positioning during sleep.
A. While it is important for the client to communicate changes in symptoms to their healthcare provider, worsening pain and tingling at night in bilateral carpal tunnel syndrome is a common symptom and may not require immediate medical intervention.
C. Elevating the hands on two pillows at night may help reduce swelling and alleviate symptoms in some individuals, but it is not specifically indicated for managing carpal tunnel syndrome.
D. Cold compresses may provide temporary relief of symptoms such as pain and inflammation, but they are not typically recommended as a primary treatment for carpal tunnel syndrome, especially before bedtime.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which Instruction regarding skin care of the portal site should the nurse provide?

Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

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?

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?

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

The nurse has identified the priority problem for the client and now must determine proper care interventions.

Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.