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 Initiating IV access with two large bore catheters allows for rapid administration of medications and fluids as needed. Additionally, reviewing the inclusion criteria for IV fibrinolytic therapy is crucial to determine if the client is eligible for this time-sensitive intervention.
Fibrinolytic therapy aims to dissolve blood clots and restore blood flow to the brain, potentially reducing the extent of neurological deficits and improving outcomes in ischemic stroke.
A While laboratory tests such as prothrombin time and platelet count may be important for assessing coagulation status and ruling out bleeding disorders, they are not the priority in the immediate management of a suspected stroke
B Aspirin is commonly used for secondary prevention of ischemic stroke, but its administration in the acute phase of a suspected stroke depends on the specific clinical scenario and treatment guidelines. Aspirin may be contraindicated if IV fibrinolytic therapy is being considered or if the type of stroke is hemorrhagic.
C Elevating the affected limb may be beneficial in certain neurological conditions to reduce swelling or edema, but it is not the priority intervention in the immediate management of a suspected stroke.

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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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

Correct Answer is D

Explanation

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

Explanation

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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.