The nurse is caring for four clients with asthma. Which client does the nurse assess first?
a. Client with a barrel chest and clubbed fingernails
b. Client with an SaO2 level of 92% at rest
c. Client whose expiratory phase is longer than the inspiratory phase
d. Client whose heart rate is 120 beats/min
D
Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise a pulse oximetry level of 92% is not consi-dered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.
You might also like to view...
During the taking of a health history, the patient states, "It really hurts back there, and sometimes it itches, too. I have even seen blood on the tissue when I have a bowel movement. Is there something there?"
The nurse should expect to see which of these upon examination of the anus? a. Rectal prolapse b. Internal hemorrhoid c. External hemorrhoid that has resolved d. External hemorrhoid that is thrombosed
A client who has long-standing diabetes mellitus and severe, burning pain in the feet and hands as a result of peripheral neuropathy asks the nurse why an antidepressant has been prescribed. What is the nurse's best response?
A. "Many people experiencing chronic pain become depressed." B. "The antidepressants may counteract the chemicals causing your pain." C. "You are less likely to become addicted from using antidepressants than you are from using other types of pain killers." D. "The antidepressants also have strong anti-inflammatory properties and can re-duce the pain you have from inflammation."
A patient is admitted with injuries sustained from a skiing accident
While completing the primary survey, the nurse suspects the patient has an injury to the spleen because of which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Heart rate 120 2. Referred pain to the left shoulder 3. Upper left quadrant abdominal pain 4. Hematuria 5. Flank ecchymosis
During an initial interview at a clinic, a young female client states that there is nothing wrong with her. Which of the following indicates to the nurse that this client might have anorexia nervosa?
A) Episodes of overeating and excessive weight gain B) Expressions of a positive self-concept C) Flexible thought patterns and spontaneity D) Severe weight loss due to self-imposed dieting