Difficulty: Medium
Average Score: 68%
Simulated
Passage / Scenario
Nurses' NotesClient admitted to the emergency department with palpitations, fatigue, weakness, and nocturia.
Client reports awakening 2 to 3 times each night to urinate.
Breath sounds scattered crackles heard bilaterally.
Client reports a dry, hacking cough, especially at night.
Apical heart rate rapid and irregular. Audible 5, gallop.
Color pale, skin cool and clammy to touch.
Vital Signs
Temperature 38.6┬░ C (101.5┬░ F)
Blood pressure 98/50 mm Hg
Pulse rate 112/min
Respiratory rate 28/min
Oxygen saturation 88% on room air
Diagnostic Results
B-type natriuretic peptide (BPN) 410 pg/mL (less than 100 pg/mL) Electrocardiogram: Atrial fibrillation
A nurse in the emergency department is caring for a client. Exhibit 1: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Rationale
Action to Take: Administer supplemental oxygen, Prepare to administer bronchodilator; Potential Condition: Asthma; Parameter to Monitor: Pulmonary function tests, Neurological Status.
Rationale:
1. Administering supplemental oxygen and preparing to administer a bronchodilator are appropriate actions for managing an asthma exacerbation.
2. Asthma is the most likely condition based on the symptoms described (wheezing, shortness of breath).
3. Monitoring pulmonary function tests can assess the client's lung function, and monitoring neurological status can help detect any complications or changes in mental status.
4. The other choices (Pulmonary embolism, Dehydration, Left-sided heart failure) do not align with the given symptoms and actions, making them incorrect options.
Rationale:
1. Administering supplemental oxygen and preparing to administer a bronchodilator are appropriate actions for managing an asthma exacerbation.
2. Asthma is the most likely condition based on the symptoms described (wheezing, shortness of breath).
3. Monitoring pulmonary function tests can assess the client's lung function, and monitoring neurological status can help detect any complications or changes in mental status.
4. The other choices (Pulmonary embolism, Dehydration, Left-sided heart failure) do not align with the given symptoms and actions, making them incorrect options.