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 C

Explanation

C. The WBC count assesses the number of white blood cells in the blood, which are key components of the immune system involved in fighting infection. An elevated WBC count (leukocytosis) may indicate an inflammatory response to infection, including bacterial colonization or superinfection of burn wounds.
A. The hematocrit measures the proportion of red blood cells in the blood and is used to evaluate for anemia or dehydration.
B. The platelet count measures the number of platelets in the blood and is used to assess for bleeding disorders or clotting abnormalities.
D. While changes in blood pH may occur in response to severe burn injuries, it is not typically the primary laboratory value assessed to determine the presence of infection.

A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath B. The client reports that symptoms seem worse when outdoors and when exercising C. episodes like this make him extremely nervous D. it has been a couple of months since he had an asthma attack E. noticed that his inhaler was expired and was worried the medication was not working

Correct Answer is ["A"]

Explanation

Subjective data refers to the symptoms reported by the client while objective data refers to the information collected on assessment of the client. During asthmatic attack, the client reports of shortness of breath, audible wheezing, inability to speak in complete sentences and a feeling of nervousness.

The use of a reliever without relief during an asthmatic attack indicates the severity of the attack. This requires intervention including the introduction of inhaled corticosteroids to reduce airway inflammation and remodeling.

The recurrence of symptoms on exposure to exercise requires the need for further advise to avoid triggers and recurrence of symptoms.

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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.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

Correct Answer is ["A"]

Explanation

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.

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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?

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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?

An adult client who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

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.