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:

Pulmonary function testing.

Mechanical ventilation.

Chest x-ray.

2 liters of oxygen via nasal cannula.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Pulmonary function testing is not the immediate priority for a client with status asthmaticus who is showing signs of respiratory failure, such as diminished breath sounds and confusion. Pulmonary function tests are useful for diagnosing and assessing the severity of asthma but are not appropriate during an acute, life-threatening exacerbation.

Choice B reason:

Mechanical ventilation is the correct intervention for a client with status asthmaticus who is exhibiting signs of respiratory failure. Diminished breath sounds and confusion indicate severe airway obstruction and hypoxia, necessitating immediate intervention to secure the airway and ensure adequate ventilation. Mechanical ventilation helps to maintain oxygenation and ventilation until the underlying cause can be treated.

Choice C reason:

A chest x-ray can be useful in diagnosing complications such as pneumothorax or pneumonia in a client with status asthmaticus, but it is not the immediate priority when the client is showing signs of respiratory failure. The primary focus should be on stabilizing the client’s respiratory status.

Choice D reason:

Administering 2 liters of oxygen via nasal cannula is not sufficient for a client with severe status asthmaticus and signs of respiratory failure. High-flow oxygen delivery methods or mechanical ventilation are required to adequately support the client’s respiratory needs.

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Correct Answer is A

Explanation

Choice A reason: The influenza vaccine and the pneumococcal pneumonia vaccine protect against different pathogens. The influenza vaccine protects against the flu virus, while the pneumococcal vaccine protects against Streptococcus pneumoniae, a common cause of bacterial pneumonia. It is important for individuals, especially those with chronic respiratory diseases, to receive both vaccines to reduce the risk of severe respiratory infections.

Choice B reason: Stating that the client is fully protected against both influenza and pneumonia with just the flu vaccine is incorrect. The flu vaccine does not provide protection against bacterial pneumonia caused by Streptococcus pneumoniae. Therefore, it is essential to receive the pneumococcal vaccine as well.

Choice C reason: While influenza can lead to secondary bacterial pneumonia, it is not accurate to say that influenza will cause pneumonia in many cases. The primary purpose of the influenza vaccine is to prevent the flu, not pneumonia. The pneumococcal vaccine specifically targets the bacteria that cause pneumonia.

Choice D reason: Suggesting that the client should get the pneumonia vaccine to prevent carrying the disease to others is not the most appropriate response. The primary reason for receiving the pneumococcal vaccine is to protect the individual from developing bacterial pneumonia, not just to prevent transmission.

A. Ask the client their date of birth and confirm it with the chart and name of surgery. B. Check the client’s medical record number and surgical consent form. C. Check the client’s armband and ask their name, date of birth, and site of surgery. D. Ask the client their name and social security number.

Correct Answer is C

Explanation

Choice A reason: Asking the client their date of birth and confirming it with the chart and name of surgery is a good practice, but it is not the most comprehensive method. This approach verifies only one identifier and does not ensure the correct surgical site.

Choice B reason: Checking the client’s medical record number and surgical consent form is important, but it does not involve direct interaction with the client. This method verifies the documentation but does not confirm the client’s identity through personal verification.

Choice C reason: Checking the client’s armband and asking their name, date of birth, and site of surgery is the best method. This approach uses multiple identifiers and involves direct interaction with the client, ensuring accurate identification and confirmation of the correct surgical site. The use of multiple identifiers reduces the risk of errors and enhances patient safety.

Choice D reason: Asking the client their name and social security number is another method of identification, but it is not as commonly used in clinical settings due to privacy concerns. Additionally, it does not confirm the surgical site.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client with chronic respiratory disease tells the nurse it is unnecessary to receive the pneumococcal pneumonia vaccine because the influenza vaccine was just received two months ago. Which response by the nurse is most appropriate?

Correct Answer is A

Explanation

Which is the best method for the nurse to correctly identify a client prior to surgery?

Correct Answer is C

Explanation

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