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 ["A","C"]
Explanation
Choice A rationale
The statement “This diagnosis means that I am crazy” requires follow-up teaching by the nurse. Mental health conditions do not equate to being “crazy”. It’s important to educate the client about the nature of their diagnosis and dispel any misconceptions.
Choice B rationale
The statement “Many people have the same response to a stressful situation as I am having right now” does not require follow-up teaching. It shows that the client understands that their reaction to stress is not uncommon.
Choice C rationale
The statement “I will probably need to be on medication for the rest of my life” requires follow-up teaching. While some conditions do require long-term medication, it’s not a certainty for all conditions. The duration of treatment can vary based on the individual’s response and the nature of their condition.
Choice D rationale
The statement “I can use holistic approaches like meditation to help my symptoms” does not require follow-up teaching. It shows that the client is open to using non-pharmacological methods to manage their symptoms, which can be a beneficial part of a comprehensive treatment plan.
Choice E rationale
The statement “I am at high risk for post-traumatic stress disorder because I have acute stress disorder” does not require follow-up teaching. It’s accurate that individuals with acute stress disorder are at a higher risk of developing post-traumatic stress disorder.
Choice F rationale
The statement “I can learn to manage my thoughts better through therapy” does not require follow-up teaching. It shows that the client understands the benefits of therapy in managing their condition.
Correct Answer is C
Explanation
Choice A rationale
Setting up supplemental oxygen delivery is not the immediate action the nurse should take. The patient’s FiO2 is currently at 35%, which is within the normal range.
Choice B rationale
Increasing the fraction of inspired oxygen is not necessary at this time. The patient’s current FiO2 is within the normal range.
Choice C rationale
The nurse should gather supplies for extubation. As the patient is due to start ventilator weaning, preparing for extubation is the next logical step. This involves having all necessary equipment and personnel ready for the procedure.
Choice D rationale
Placing a nasogastric tube is not the immediate action the nurse should take. While a nasogastric tube can be used to provide nutrition and medication, it is not directly related to the process of ventilator weaning.
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