The nurse is caring for a patient newly diagnosed with asthma. Which assessment data indicates the need for an immediate intervention?

Bradypnea.

Decreased respiratory rate

Increased crackles

Diminished breath sounds

Answer and Explanation

The Correct Answer is D

A.   Bradypnea, or a slow respiratory rate, is concerning but not typically associated with asthma exacerbations. In asthma, patients usually experience tachypnea (increased respiratory rate) as they try to compensate for difficulty breathing.
B.   A decreased respiratory rate in an asthma patient can be alarming, but it may not necessarily indicate an immediate need for intervention unless it’s associated with other severe symptoms. In general, asthma patients often have an increased respiratory rate due to respiratory distress.
C.   While crackles can indicate fluid in the lungs and may suggest an underlying issue, they are not the most immediate concern in a patient with asthma. Crackles can occur in various conditions, and they alone may not necessitate urgent intervention.
D.   Diminished breath sounds are a critical finding in asthma patients. This may indicate severe airway obstruction or a lack of air movement due to severe bronchospasm. In the context of asthma, diminished breath sounds can signify that the patient is not able to move air effectively, which requires immediate intervention to prevent respiratory failure.

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Correct Answer is D

Explanation

A. This response may downplay the significance of the current elevated blood pressure reading. Given that the reading indicates stage 2 hypertension, waiting two months without further assessment could be inappropriate, as the patient may be at risk for complications.
B. This option suggests a follow-up in a reasonable timeframe. It acknowledges the need for a prompt reassessment but still allows for some delay. However, it may not convey the urgency that may be warranted given the current high reading.
C. While this option provides a specific timeframe for follow-up, it may also imply that the situation is less urgent than it is. A week could be too long to wait for someone with a reading indicative of hypertension, especially considering potential risks.
D. This is the best response because it prioritizes the patient's health by recommending immediate evaluation. The current blood pressure reading of 160/96 mmHg is significantly elevated and may warrant urgent assessment to rule out any underlying conditions, initiate management, and prevent complications such as cardiovascular events.

A. Orange Juice. B. Red gelatin. C. Vanilla milkshake. D. Banana.

Correct Answer is B

Explanation

A. Orange juice is acidic, which can irritate a healing throat after a tonsillectomy. This acidity may cause discomfort and is generally not recommended in the early postoperative period.
B. Red gelatin is often considered a suitable option after a tonsillectomy because it is soft, easy to swallow, and typically well-tolerated. However, the color (red) may sometimes be avoided in some healthcare settings due to concerns that it can resemble blood in the event of bleeding.
C. A vanilla milkshake is creamy and can be soothing. However, if the milkshake is thick or cold, it may cause some discomfort for the patient. Additionally, the richness of a milkshake could be heavier than what is typically recommended immediately after surgery.
D. While bananas are soft and easy to swallow, they may not be the best choice right after a tonsillectomy. They can be somewhat sticky and may require more chewing, which could be uncomfortable for the patient at this stage.

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The nurse is caring for a patient newly diagnosed with asthma. Which assessment data indicates the need for an immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

At a community health fair, the blood pressure of a 62-year-old patient is 160/96 mmHg. The patient states "My blood pressure is usually much lower." What is the best response by the nurse?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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