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Patient Data

History and Physical

The client is a 22-year-old female with a history of asthma. She was diagnosed at the age of 4 years old and has had 2 previous hospitalizations for asthma-related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week. She reports taking edible marijuana to relieve severe premenstrual symptoms. She came to the emergency department when she started having difficulty breathing on a hike. She took her usual dose of albuterol, but the symptoms did not resolve. The client’s friend called an ambulance when they noticed her distress.

Nurses’ Notes

The client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally.

Vital Signs

Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.

Click to highlight the assessment findings that require immediate follow up by the nurse.

diagnosed at the age of 4 years old and has had 2 previous hospitalizations

reports taking edible marijuana

started having difficulty breathing on a hike

took her usual dose of albuterol, but the symptoms did not resolve

mild subcostal retractions

Wheezes are noted throughout the lung fields

client is pale

heart rate is 122 beats/minute

blood pressure 134/85 mm Hg

oxygen saturation 91% on room air

Answer and Explanation

The Correct Answer is ["C","D","E","F","G","H","J"]

Based on the provided information, the following assessment findings require immediate follow-up by the nurse:

Difficulty breathing on a hike: This is a significant symptom of asthma exacerbation and needs immediate attention.
Symptoms did not resolve after taking albuterol: Albuterol is a quick-relief medication for asthma symptoms. If symptoms do not improve after its use, it indicates that the asthma exacerbation is severe.
Mild subcostal retractions: This is a sign of respiratory distress and indicates that the client is using accessory muscles to breathe.
Wheezes noted throughout the lung fields: Wheezing is a common sign of asthma and indicates airway obstruction.
The client is pale: Paleness can be a sign of decreased oxygenation.
Heart rate of 122 beats/minute: A high heart rate can be a sign of distress or could be due to the body’s attempt to compensate for decreased oxygenation.
Oxygen saturation of 91% on room air: Normal oxygen saturation is typically 95% or higher. A saturation of 91% indicates that the client is not getting enough oxygen.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

A rotator cuff injury could be a possibility given the patient’s age and the nature of the fall. The rotator cuff is a group of muscles and tendons that surround the shoulder joint, and injuries to this area are common in falls where the shoulder takes the impact.

Choice B rationale

A humeral fracture could also be a possibility. The humerus is the bone in the upper arm, and it can be fractured in falls, especially in older adults who may have weaker bones.

Choice C rationale

A concussion could be a possibility given that the patient hit his head on the wall. Symptoms of a concussion can include nausea and fatigue, which the patient is experiencing.

Choice D rationale

A knee sprain could be a possibility given that the patient is experiencing pain in his right knee. Sprains occur when the ligaments, which are the bands of tissue that hold bones together, are stretched or torn.

Correct Answer is ["18"]

Explanation

Step 1 is to calculate the infusion rate. The prescription is for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline.

So, the calculation would be (900 units ÷ 25,000 units) × 500 mL = 18 mL/hr.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D"]

Explanation

A client receives a prescription for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline. How many mL/hr should the nurse program the infusion pump to deliver?

Correct Answer is ["18"]

Explanation

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