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 ["8"]
Explanation
Given:
IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline.
The prescribed rate is 8 units/hr.
First, we find out how many units are present in 1 mL of the IV solution: 100 units / 100 mL = 1 unit / 1 mL
Now, since the prescribed rate is 8 units/hr, we need to infuse 8 mL/hr of the IV solution to deliver 8 units of insulin per hour.
So, the nurse should program the infusion pump to deliver 8 mL/hr.
Correct Answer is A
Explanation
A. Observing the insertion site of the suprapubic catheter is crucial to assess for signs of infection, such as redness, swelling, or drainage. Any abnormalities at the insertion site should be reported promptly for further evaluation and intervention.
B. Palpating the flank area may not be directly related to the care of the suprapubic catheter unless there are specific concerns or symptoms related to the renal system that warrant assessment of the kidneys.
C. While measuring abdominal girth can provide information about abdominal distention or fluid accumulation, it may not directly address the care needs related to the suprapubic catheter unless there are specific concerns related to catheter function or drainage.
D. Assessing the perineal area may be relevant for clients with other types of urinary catheters (e.g., indwelling urethral catheters), but for clients with a suprapubic catheter, the focus is on the site of catheter insertion in the lower abdomen.
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