Nokea
A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
- A. Palpate the right flank for tenderness.
- B. Test the urine for the presence of hematuria.
- C. Evaluate the urine for a strong odor.
- D. Measure the temperature and pulse rate.
Correct Answer: D
Rationale: Measuring temperature and pulse rate is important to identify signs of systemic infection or inflammation contributing to the client's symptoms.
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Nurses' Notes
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.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize [condition] as the priority problem for this client, as evidenced by the client's statement, [statement].
- A. chronic bronchitis
- B. anxiety disorder
- C. exercise-induced bronchospasm
- D. impaired gas exchange
- E. cardiovascular disease
- F. respiratory infection
Correct Answer: D
Rationale: The client's difficulty breathing, need to pause to catch breath, ineffective rescue inhaler, and oxygen saturation of 88% indicate impaired gas exchange, requiring immediate intervention to improve respiratory function.
History and Physical Nurses' Notes
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.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Orders
Administer albuterol 2.5 mg/ipratropium bromide 0.5 mg in 3 mL solution via nebulizer four times a day and PRN.
Administer prednisone 60 mg PO
Administer oxygen to keep oxygen saturation greater than 94%, titrate as needed.
The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful.
- A. Decrease in heart rate from 112 to 105 beats per minute.
- B. Client able to speak in full sentences without pausing.
- C. Clear lung sounds.
- D. Reduction in respiratory rate to 16 breaths per minute.
- E. Client reports breathing is eased.
- F. Blood pressure within normal limits.
Correct Answer: A,B,C,D,E,F
Rationale: The assessment data showing decreased heart rate, ability to speak in full sentences, clear lung sounds, reduced respiratory rate, eased breathing, and stable blood pressure all indicate successful interventions for the asthma attack.
Initial Assessment
Orders
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 nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
- A. Provide client teaching
- B. Apply oxygen via nasal cannula.
- C. Ask the client for a list of current medications.
- D. Place the client in Trendelenburg position.
- E. Notify the healthcare provider of the client's need for intubation.
- F. Administer medications as ordered.
Correct Answer: A,B,C,F
Rationale: Client education, oxygen therapy, obtaining medication history, and administering ordered medications address the client's asthma exacerbation and promote effective management.
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?
- A. 125
Correct Answer: A
Rationale: To calculate: 3000 mL / 24 hr = 125 mL/hr. The nurse should program the infusion pump to deliver 125 mL/hr.
After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Right foot pale with sluggish capillary refill.
- B. Circumferential edema of right foot.
- C. Reports throbbing right leg pain.
- D. Increased temperature to lower extremity.
Correct Answer: A
Rationale: A pale right foot with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, requiring immediate intervention to prevent tissue damage.