The nurse prioritizes impaired gas exchange as a problem for a client with an asthma exacerbation. Which of the following is the client’s priority goal?

The client will demonstrate decreased episodes of coughing at night.

The client’s pulse oximetry values will remain above 94% on room air for the majority of the time.

The client’s breath sounds will only have slight wheezing by discharge.

The client will correctly demonstrate the use of a peak flow meter.

Answer and Explanation

The Correct Answer is B

Maintaining adequate oxygenation is the primary goal for a client with impaired gas exchange due to an asthma exacerbation. Pulse oximetry is a non-invasive method to monitor the oxygen saturation of a patient’s blood, and values above 94% indicate sufficient oxygenation.

Choice A reason:

The client will demonstrate decreased episodes of coughing at night is important but not the priority goal. While reducing coughing can improve comfort and sleep quality, it does not directly address the critical issue of impaired gas exchange. The primary concern in an asthma exacerbation is ensuring that the client maintains adequate oxygen levels.

Choice B reason:

The client’s pulse oximetry values will remain above 94% on room air for the majority of the time is the priority goal. This goal directly addresses the issue of impaired gas exchange by ensuring that the client maintains adequate oxygenation. Pulse oximetry values above 94% indicate that the client’s blood is sufficiently oxygenated, which is crucial for preventing hypoxemia and ensuring that the body’s tissues receive enough oxygen to function properly.

Choice C reason:

The client’s breath sounds will only have slight wheezing by discharge is a relevant goal but not the priority. While reducing wheezing is an indicator of improved airway function, it is not as directly measurable or critical as maintaining adequate oxygen saturation. Wheezing can persist even when oxygen levels are adequate, so it is not the most reliable indicator of improved gas exchange.

Choice D reason:

The client will correctly demonstrate the use of a peak flow meter is an important educational goal but not the priority in an acute setting. Proper use of a peak flow meter can help the client monitor their asthma and prevent future exacerbations, but it does not directly address the immediate issue of impaired gas exchange. The priority in an acute asthma exacerbation is to ensure that the client is adequately oxygenated.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Asking if the client has ever had pneumonia does not confirm a diagnosis of chronic bronchitis. Pneumonia is an acute infection of the lungs, whereas chronic bronchitis is a long-term condition characterized by persistent inflammation of the airways. While a history of pneumonia might be relevant to the client’s overall respiratory health, it is not specific to diagnosing chronic bronchitis.

Choice B reason: Inquiring about a recent bronchoscopy does not confirm chronic bronchitis. Bronchoscopy is a diagnostic procedure used to visualize the airways and collect samples, but it is not a criterion for diagnosing chronic bronchitis. The diagnosis is based on clinical symptoms and history rather than recent procedures.

Choice C reason: The question about a consistent cough for three months in the last two years directly relates to the diagnostic criteria for chronic bronchitis. Chronic bronchitis is defined by a productive cough that lasts for at least three months in two consecutive years. This question helps to confirm the chronic nature of the client’s symptoms, which is essential for diagnosis.

Choice D reason: Asking if the client has had the flu in the past year does not confirm chronic bronchitis. Influenza is a viral infection that can cause acute respiratory symptoms, but it is not related to the chronic inflammation seen in chronic bronchitis. This question might be relevant for understanding the client’s recent health history but does not aid in diagnosing chronic bronchitis.

A. Listening to at least one full respiration in each location. B. Instructing the client to breathe in and out rapidly while listening to breath sounds. C. Listening to breath sounds through the hospital gown or clothing. D. Instructing the client to take slow deep breaths through his or her nose. E. Listening as the client inhales, then goes to the next site during exhalation.

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

Explanation

Choice A reason: Listening to at least one full respiration in each location is a proper technique for respiratory assessment. It ensures that the nurse can accurately assess the breath sounds and identify any abnormalities. This method allows for a thorough evaluation of the respiratory system, ensuring that no areas are missed.

Choice B reason: Instructing the client to breathe in and out rapidly while listening to breath sounds is incorrect. Rapid breathing can lead to hyperventilation and may not provide an accurate representation of the client’s normal breath sounds. The proper technique is to instruct the client to take slow, deep breaths through their mouth, which allows for a more accurate assessment of the breath sounds and any potential abnormalities.

Choice C reason: Listening to breath sounds through the hospital gown or clothing is incorrect. Clothing can interfere with the sounds and may lead to inaccurate assessments. The proper technique is to place the stethoscope directly on the client’s skin to ensure that the breath sounds are heard clearly and accurately.

Choice D reason: Instructing the client to take slow deep breaths through his or her nose is partially correct but not ideal. While slow deep breaths are appropriate, they should be taken through the mouth to ensure that the breath sounds are more pronounced and easier to assess. Breathing through the nose can sometimes muffle the sounds and make it harder to detect abnormalities.

Choice E reason: Listening as the client inhales and then moving to the next site during exhalation is incorrect. The nurse should listen to both the inhalation and exhalation phases of respiration at each site. This ensures a complete assessment of the breath sounds and helps in identifying any abnormalities that may be present during either phase of respiration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse prioritizes impaired gas exchange as a problem for a client with an asthma exacerbation. Which of the following is the client’s priority goal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the history of a client admitted with newly diagnosed chronic bronchitis. Which question by the nurse confirms this diagnosis?

Correct Answer is C

Explanation

The experienced nurse understands that the student nurse may require additional instruction regarding proper respiratory assessment techniques when the nurse observes the student: (SELECT ALL THAT APPLY)

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

Explanation

The nurse recognizes which of the following tests will confirm the diagnosis of tuberculosis for a client?

The nurse receives an order to administer drug R 300 mg IVPB over one hour. Drug R is available as 300 mg in 100 mL NSS. The drip factor of the piggyback tubing is 15 gtts/mL. At what rate should the nurse regulate the IV flow?

The client diagnosed with pneumonia asks the nurse, “Why did my physician order chest physiotherapy (CPT) for me?” Which response by the nurse is most accurate? Chest physiotherapy will:

The nurse is assisting the client with arm and shoulder exercises on the first post-op day following a right-sided thoracotomy. The client reports pain with the exercise and wants to know why they must be performed. What explanation should the nurse provide? The exercises:

The nurse is completing an admission assessment on a client diagnosed with asthma. What clinical manifestations are typical of the disorder?

The nurse recognizes the assessment data which best indicates that the client diagnosed with asthma is achieving good control with the prescribed medication regimen is when:

What information would be important for the nurse to reinforce when teaching a pre-operative client about the correct use of the patient-controlled analgesia (PCA) device to achieve the best outcome?

While assessing a client with status asthmaticus, the nurse notes diminished breath sounds in all lung fields and the client is becoming confused. The nurse should prepare the client for: