A 26-year-old female is brought to the emergency department while having an asthma attack. She is given a nebulizer treatment with the medication albuterol. The nurse's immediate assessment priority would be to
Determine the time of the patient's last meal.
Monitor the patient's temperature and blood pressure.
Monitor respiratory rate and Spo2 with a pulse oximeter.
Provide education on asthma management and treatment.
The Correct Answer is C
During an asthma attack, the primary concern is the patient's ability to breathe and maintain adequate oxygenation. Monitoring the patient's respiratory rate and oxygen saturation (SpO2) with a pulse oximeter provides crucial information about the effectiveness of the albuterol treatment and the patient's respiratory status. It helps determine if the airway is opening up, if oxygen levels are improving, and if the patient is responding positively to the medication.
While determining the time of the patient's last meal can be relevant for certain interventions, it is not the immediate priority during an asthma attack. It is more important to focus on assessing and managing the patient's breathing and oxygenation first.
Monitoring the patient's temperature and blood pressure can be important for a comprehensive assessment, but they are not the immediate priority during an acute asthma attack. Addressing the patient's respiratory distress takes precedence.
Providing education on asthma management and treatment is an important aspect of care, but it should be done after the patient's acute symptoms are addressed and stabilized. In the immediate assessment phase, the focus is on assessing and managing the patient's respiratory status. Education can be provided once the patient's immediate needs are addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Codeine is an opioid medication that can cause drowsiness and dizziness. Changing positions quickly, especially from lying down to standing up, can increase the risk of falls or accidents.
Instructing the client to change positions slowly helps prevent orthostatic hypotension (a drop in blood pressure upon standing) and reduces the risk of falls.
The other options listed are not appropriate instructions for a client taking codeine:
A. "You should expect to experience diarrhea while taking this medication." While constipation is a common side effect of opioids, diarrhea is not typically associated with codeine use. Therefore, there is no need to expect or warn about diarrhea as an anticipated effect of taking codeine.
C. "You should limit alcohol intake to 12 ounces daily." Mixing alcohol with codeine can have harmful effects, such as increased sedation and respiratory depression. However, it is generally recommended to avoid alcohol completely while taking codeine, rather than setting a specific limit of 12 ounces daily.
D. "You should take the medication on an empty stomach to prevent nausea." Taking codeine with or without food can vary depending on individual factors and the specific instructions provided by the healthcare provider. However, taking codeine on an empty stomach does not necessarily prevent nausea. In fact, taking it with food may help reduce stomach upset for some individuals. It is best to follow the specific instructions provided by the healthcare provider regarding the timing of codeine administration with or without food.
Correct Answer is D
Explanation
Dry mouth is a common side effect of diphenhydramine, which is an antihistamine medication commonly used to relieve symptoms of allergies, including itching and rash. Chewing on sugarless gum or sucking on hard, sour candies can help stimulate saliva production and alleviate the discomfort of dry mouth.
A. "Administer the medication with food": While taking diphenhydramine with food may help reduce the risk of stomach upset, it does not directly address the dry mouth side effect.
B. "Discontinue the medication and notify your provider": Discontinuing the medication without consulting the healthcare provider is not recommended unless specifically instructed to do so. Dry mouth is a common side effect of diphenhydramine and can be managed with supportive measures.
C. "Place a humidifier at your bedside every evening": While using a humidifier can help add moisture to the air and potentially alleviate dryness in the environment, it is not a specific instruction for managing dry mouth caused by diphenhydramine.
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