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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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A rationale

Printing the electronic medical record (EMR) from the backup server may not be the most immediate action required. While having a backup of the EMR is important, it does not address the immediate issue of the system failure.

Choice B rationale

Waiting for notification that the system has been rebooted is a passive approach and may not be the most effective initial action. It does not address the immediate need to communicate the issue to the appropriate department.

Choice C rationale

Identifying information as a late entry in the record is a documentation practice that is used when charting is not completed in a timely manner. However, this action does not address the immediate issue of the system failure.

Choice D rationale

Notifying the information services department of the situation is the correct action. This allows the appropriate department to begin troubleshooting and resolving the issue. In the event of a system failure, the first step should be to report the issue so that it can be addressed as quickly as possible.

A. Clarify reality with the client about delusional thoughts. B. Reduce the client’s interaction with others during the day. C. Awaken the client earlier for daily morning care. D. Use distraction and therapeutic communication skills.

Correct Answer is D

Explanation

Choice A rationale

Clarifying reality with the client about delusional thoughts is not the most effective approach when dealing with a client with dementia who is experiencing agitation and delusional thoughts. The cognitive impairment associated with dementia may make it difficult for the client to understand or accept the clarification, which could lead to increased frustration and agitation.

Choice B rationale

Reducing the client’s interaction with others during the day is not the most appropriate approach in this situation. It may lead to increased social isolation and could potentially worsen the client’s agitation and delusions. It does not directly address the client’s emotional distress.

Choice C rationale

Awakening the client earlier for daily morning care may further disrupt the client’s sleep patterns and potentially worsen agitation. It does not address the underlying issue of delusional thoughts and the client’s emotional distress.

Choice D rationale

Using distraction and therapeutic communication skills is the most suitable approach for a client with dementia who is experiencing agitation and delusional thoughts. Distraction techniques can help redirect the client’s focus away from distressing thoughts, and therapeutic communication skills, such as active listening and validation, can help the client feel understood and supported.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After a scheduled downtime, the computer documentation system fails to restart.What should be the nurse’s initial action?

Correct Answer is D

Explanation

An older adult client with dementia is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing.The client is becoming increasingly agitated and stating the UAP “wants to hurt me and tie me up.”. Which approach should the nurse use with this client?

Correct Answer is D

Explanation

A nurse is caring for a patient who has undergone a small bowel resection and has a history of methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention is most crucial to minimize the risk of a MRSA recurrence in the postoperative wound?

What advice should a nurse give to a patient who is about to undergo a cystoscopy?

A parent brings a 4-month-old infant to the clinic.The infant has had a runny nose, a slight fever, and a cough for the last two days.Which of the following findings should alert the nurse that the child is in acute respiratory distress?

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines.Which instruction should the nurse provide the parent about care of the infant after the injections?

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.Which action should the nurse include during the assessment?

Which client statements require follow-up teaching by the nurse? Select all that apply.