The nurse reviews the client history of the presenting illness in the electronic medical record.

Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.

A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.

The client reports using a rescue inhaler three times, but he just couldn't catch his breath

symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous

inhaler was expired and was worried the medication was not working

able to answer questions, pausing every few words to catch his breath

The client reports that it has been a couple of months since he had an asthma attack

Answer and Explanation

The Correct Answer is ["A","B"]

In the provided scenario, the two key pieces of subjective data indicating the need for health interventions are the client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise. These details suggest that the client's asthma is not well-controlled, and the ineffectiveness of the rescue medication, especially with an expired inhaler, warrants immediate medical attention.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","E"]

Explanation

A. This intervention is likely to be ordered due to the patient's fever and elevated heart rate, which may suggest dehydration or the need for increased fluid intake to support hemodynamic stability and mitigate the effects of fever and potential dehydration from fever and nausea.

B. Given the diagnosis of Pneumocystis pneumonia, the patient will likely be on or start antibiotics specific to this infection, such as trimethoprim-sulfamethoxazole. Monitoring for adverse reactions is crucial, especially in a newly diagnosed HIV- positive patient who might be starting multiple new medications.
C. While it is important to monitor CD4 counts in HIV-positive patients to guide treatment decisions, repeating the CD4 count immediately might not be prioritized unless there are specific clinical changes that suggest a rapid decline in immune function. Given the recent test results showing a CD4 count of 443 cells/mm^3, immediate retesting might not be clinically justified unless guided by other symptoms or considerations not detailed here.
D. Pneumocystis pneumonia does not require airborne isolation as it is not typically contagious between people under normal circumstances. Instead, it arises as an opportunistic infection in individuals with weakened immune systems. Hence, this order would not be appropriate unless there were other infections suspected that require such precautions.
E. The patient reports severe nausea, which not only is distressing but can also prevent the patient from taking oral medications and maintain necessary nutrition. Administering an antiemetic can help manage this symptom effectively.

Correct Answer is ["125"]

Explanation

To calculate the infusion rate in mL/hr, you would convert the total volume of lactated Ringer's IV from liters to milliliters (since there are 1,000 milliliters in a liter, 3 liters is equivalent to 3,000 milliliters) and then divide by the total number of hours over which the infusion is to be administered. In this case, 3,000 mL divided by 24 hours results in an infusion rate of 125 mL/hr.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only)

Correct Answer is ["125"]

Explanation

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