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 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 difficulty in breathing.
Click to highlight the assessment findings that require immediate follow up by the nurse.
- 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.
- Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg. Oxygen saturation is 91% on room air.
She has mild subcostal retraction
sitting in an upright position
Wheezes are noted throughout the lung fields
The client is pale
Her heart rate is 122 beats/minute
Oxygen saturation is 91% on room air
strong peripheral pulses that are equal bilaterally
client is admitted to the medical floor
blood pressure 134/85 mm Hg
The Correct Answer is ["A","B","C","D","E","F"]
The assessment findings that require immediate follow up by the nurse are: The client has mild subcostal retractions. This could indicate that she is using accessory muscles to breathe, which is a sign of respiratory distress. The client is sitting in an upright position. This is a common position for people who are having difficulty breathing because it allows for maximum expansion of the lungs. Wheezes are noted throughout the lung fields. Wheezing can be a sign of an obstructive process such as asthma. The client is pale. Paleness can be a sign of decreased oxygenation. Her heart rate is 122 beats/minute, which is above the normal range and can indicate that her body is working harder to get oxygen. Her oxygen saturation is 91% on room air. Normal oxygen saturation is generally 95% or higher, so this could indicate that she is not getting enough oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A blood pressure of 100/60 mm Hg is not typically considered a risk for patients receiving eptifibatide. While eptifibatide can cause hypotension, a blood pressure of 100/60 mm Hg is within normal limits.
Choice B rationale
The presence of hematemesis, or vomiting blood, poses the greatest risk to the patient. Eptifibatide is a glycoprotein IIb/IIIa inhibitor that prevents platelets from clumping together by blocking the action of certain proteins. This can increase the risk of bleeding, including gastrointestinal bleeding, which could manifest as hematemesis.
Choice C rationale
Incontinence with blood in the urine could indicate a urinary tract infection or other urinary system issue, but it is not typically associated with the use of eptifibatide.
Choice D rationale
Unresponsiveness to painful stimuli is a serious symptom that could indicate a number of issues, including neurological damage or severe illness. However, it is not typically associated with the use of eptifibatide.
Correct Answer is B
Explanation
Choice A rationale
Initiating bilateral intermittent sequential pneumatic compression devices is not the most appropriate immediate intervention for a patient showing signs of a possible stroke. These devices are typically used to prevent deep vein thrombosis in patients who are immobile, not for stroke management.
Choice B rationale
Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is the correct intervention. This position can help reduce intracranial pressure and facilitate venous drainage. In the case of a suspected stroke, it’s crucial to maintain proper cerebral blood flow.
Choice C rationale
Maintaining elevated positioning of the dependent joints on the affected side is not the immediate priority in stroke management. While it’s important to prevent contractures and maintain functional positioning, the immediate concern is to stabilize the patient’s condition.
Choice D rationale
Obtaining a focused history to determine recent bleeding and use of anticoagulants is important, but it’s not the first intervention. While this information will be necessary for the healthcare provider to determine the appropriate course of treatment, the immediate priority is to manage the patient’s acute symptoms.
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