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

Answer and Explanation

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.

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Correct Answer is ["B","H"]

Explanation

A. Chesty: Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.
B. Start oxygen 3 L via nasal cannulA Increased oxygen flow is necessary to manage the

client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C. Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.

D. Normal saline 150 ml/hour: Helps maintain hydration but is secondary to respiratory support in this scenario.
E. NPO: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F. Start an IV: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G. Sputum culture: Useful for diagnosing the cause of respiratory symptoms but not a first- line action.
H. Place the client on a cardiorespiratory monitor: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.

A. When the client has ankle edema. B. If the client has an elevated blood pressure. C. During admission to labor and delivery. D. Within the first trimester of pregnancy.

Correct Answer is B

Explanation

A. Assessing DTRs when the client has ankle edema is important, but it is not the most critical time. Ankle edema can be a common occurrence in pregnancy due to increased fluid volume and changes in blood flow.

B. Elevated blood pressure in a pregnant client can be a sign of preeclampsia, a serious condition that can lead to complications for both the mother and the baby. Assessing DTRs can help in
detecting hyperreflexia, which is a sign of preeclampsia. Therefore, it is most important to assess DTRs when there is an elevated blood pressure.

C. While assessing DTRs during admission to labor and delivery is a standard procedure to monitor the client's neurological status, it is not as critical as assessing them when there is an elevated blood pressure.

D. Assessing DTRs within the first trimester of pregnancy is not typically a priority unless there are specific clinical indications or concerns. Elevated blood pressure is a more immediate
concern that requires prompt assessment of DTRs

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","H"]

Explanation

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

Correct Answer is B

Explanation

The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/dl (325 Mcmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan?

A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg intravenously every 12 hours. The vial is labeled, "10 mg/mL." How many mL should the nurse administer? (Enter numeric value only)

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

Patient data Exhibits The nurse is reviewing the orders for the infant of a diabetic mother to determine priorities Which 6 orders take priority?

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse serves that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 6 mcg/kg/min. Which intervention should the nurse implement while administering this medication?