The patient is resting in bed and cooperative with her mother at her bedside.
Which of the following assessments were made?

Neurological: Agitation. Oriented x. Dizziness. Pupils equal and reactive to light.

Cardiovascular: Bradycardia. Bilateral radial pulses weak. Capillary refill 2 seconds. No lower leg edema noted.

Respiratory: Clear breath sounds.

Gastrointestinal: Last reported bowel movement 4 days ago.

Answer and Explanation

Correct Answer : C

Choice A rationale

The patient is resting and cooperative, which indicates a calm and alert state, not agitation. Orientation x means the patient is aware of person, place, time, and situation, which is a normal finding. Dizziness is not mentioned in the patient’s condition. Pupils being equal and reactive to light is a normal finding and does not indicate a neurological issue.

Choice B rationale

Bradycardia refers to a slower than normal heart rate, which is not mentioned in the patient’s condition. Weak bilateral radial pulses could indicate poor blood circulation, but this is not mentioned in the patient’s condition. Capillary refill of 2 seconds is a normal finding. The absence of lower leg edema is a normal finding and does not indicate a cardiovascular issue.

Choice C rationale

Clear breath sounds are a normal finding and indicate that the patient’s lungs are free of obstructions or fluid.

Choice D rationale

The last reported bowel movement being 4 days ago could indicate constipation, but this is not mentioned in the patient’s condition.

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Correct Answer is ["A","C","F","H"]

Explanation

Choice A rationale

Monitoring the oxygen saturation is an important nursing intervention following the administration of albuterol. Albuterol is a bronchodilator and should improve oxygen saturation by increasing airflow and oxygen delivery.

Choice B rationale

Deep tracheal suctioning is not typically required following the administration of albuterol unless the patient has excessive secretions or difficulty clearing secretions.

Choice C rationale

Discussing potential asthma triggers with the client is an important nursing intervention. Understanding and avoiding triggers can help prevent future asthma exacerbations.

Choice D rationale

Obtaining a sputum culture is not typically required following the administration of albuterol unless there is a suspicion of a respiratory infection.

Choice E rationale

Positive pressure ventilation is not typically required following the administration of albuterol unless the patient is in severe respiratory distress.

Choice F rationale

Allowing the client to take a position of comfort can help improve breathing and should be encouraged.

Choice G rationale

Discussing aggressive respiratory treatment options is not typically required following the administration of albuterol unless the patient’s condition is not improving or worsening.

Choice H rationale

Weaning the supplemental oxygen may be appropriate following the administration of albuterol if the patient’s oxygen saturation has improved.

A. Limit activity for a day or two after returning home. B. Anticipate a stinging feeling during needle insertion. C. Prepare to sit forward with arms propped on a table. D. Expect a persistent cough after the procedure.

Correct Answer is D

Explanation

Choice A rationale

Limiting activity for a day or two after returning home is a correct understanding. After a thoracentesis, it’s recommended to limit activity for a day or two to allow the body to recover.

Choice B rationale

Anticipating a stinging feeling during needle insertion is a correct understanding. The patient will feel a stinging sensation when the local anesthetic is injected.

Choice C rationale

Preparing to sit forward with arms propped on a table is a correct understanding. This position helps to expand the space between the ribs, making it easier for the doctor to access the pleural space.

Choice D rationale

Expecting a persistent cough after the procedure indicates a need for additional education. While a mild cough immediately after the procedure is normal, a persistent cough could indicate a complication such as a pneumothorax.

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The patient is resting in bed and cooperative with her mother at her bedside. Which of the following assessments were made?

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Naxlex Comprehensive Predictor Exams

Following the administration of albuterol and the subsequent assessment, what actions should the nurse plan for the rest of the shift?

Correct Answer is ["A","C","F","H"]

Explanation

The nurse is preparing a client for an outpatient thoracentesis.Which statement made by the client indicates a need for additional education?

Correct Answer is D

Explanation

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The patient is resting in bed and cooperative with her mother at her bedside.
Which of the following assessments were made?