The client is a 49-year-old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the emergency department (ED last night when he was having more difficulty breathing. He has a history of one-half pack a day cigarette smoking for 20 years. He has no significant medical or surgical history
The client has an oxygen saturation of 96% on 8 L simple face mask. The nurse assesses the client, and he is feeling less restless and anxious. His heart rate is now 79 bpm, blood pressure 119/73 mmHg, and respiratory rate 24.
What are the 3 most important goals that would help the nurse evaluate the treatment of this client at discharge?
The client will report pain less than 3/10
The client will have quit smoking
The client will remain free of skin breakdown
The client will maintain oxygen saturation of 96% without supplemental oxygen
The client will be afebrile for 24 hours
Correct Answer : B,D,E
A. While managing pain is important, the client did not report significant pain, making it a lower priority in this scenario.
B. Quitting smoking is crucial for the client's respiratory health, especially given the history of smoking and current respiratory symptoms.
C. There is no indication that the client is at risk of skin breakdown; thus, it is not a priority in the immediate discharge plan.
D. Maintaining an oxygen saturation of 96% without supplemental oxygen is a direct indicator of improved respiratory function and a key goal for discharge.
E. Being afebrile for 24 hours would indicate that the infection is under control, which is a primary concern for discharge after presenting with flu-like symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. Consuming foods high in saturated fats can contribute to the progression of coronary artery
disease by increasing levels of LDL cholesterol, which can lead to plaque buildup in the arteries. Therefore, advising the client to consume foods with saturated fats would be counterproductive to slowing the progression of the disease.
B. Walking for 30 minutes per day is a beneficial lifestyle change that can help improve
cardiovascular health by promoting physical activity and increasing circulation. This statement does not require additional education.
C. Using a salt substitute may be advisable for individuals with coronary artery disease to reduce sodium intake and lower blood pressure. This statement does not require additional education.
D. Keeping a food diary is a helpful strategy for monitoring dietary habits and identifying areas for improvement. This statement does not require additional education.
E. Eating more canned vegetables may not be the healthiest choice as canned vegetables often contain added sodium, which can contribute to hypertension and cardiovascular disease.
Encouraging the consumption of fresh or frozen vegetables would be a better dietary recommendation.
F. Including oatmeal for breakfast is a nutritious choice that can help lower cholesterol levels and improve heart health. This statement does not require additional education.
Correct Answer is D
Explanation
A. Explaining that the dosage has been changed is not appropriate without confirming the accuracy of the prescription.
B. Telling him to take the medication and verifying the dosage later could result in harm if the dosage is incorrect.
C. Informing him that he may refuse the medication is an option, but it does not address the potential error in dosage.
D. Withholding the medication until the dosage can be confirmed is the safest action to prevent potential medication errors
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