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 A
Explanation
A. Albuterol is a bronchodilator that provides quick relief by relaxing the muscles around the airways, making it essential to use before a corticosteroid like beclomethasone, which reduces inflammation. Using albuterol first allows for better delivery of the beclomethasone to the airways.
B. I will use both medications immediately after exercising. Albuterol may be used as a rescue inhaler before exercise to prevent exercise-induced bronchospasm, but beclomethasone is a maintenance medication and should not be used immediately after exercising unless prescribed.
C. "If my breathing begins to feel tight, I will use the beclomethasone inhaler immediately.” Beclomethasone is a long-term control medication, not a rescue inhaler. If breathing feels tight or there is an asthma attack, the client should use the albuterol inhaler for immediate relief.
D. I will administer the medications 10 minutes apart.While there is no strict rule about the timing between inhaler uses, the albuterol should be used first to open the airways, and while waiting a few minutes is acceptable, the emphasis should be on using albuterol before beclomethasone rather than a specific time frame.
Correct Answer is D
Explanation
Acetylcysteine has a strong and distinct odor, often described as a sulfur-like smell. It is important for the adolescent to be aware of this characteristic odor so that they do not become alarmed or concerned when they encounter it.
The other options mentioned are incorrect:
A. It is necessary to monitor your serum electrolyte levels: Monitoring serum electrolyte levels is not typically required with oral acetylcysteine therapy. However, it is important to follow the healthcare provider's instructions regarding monitoring and follow-up appointments.
B. "You should avoid eating eggs": There is no specific dietary restriction or need to avoid eating eggs while taking oral acetylcysteine. However, it is always advisable to follow a balanced and healthy diet.
C. "Your mouth will become dry!": Dry mouth is not a common side effect of oral acetylcysteine. Side effects may vary from person to person, but dry mouth is not typically associated with this medication.
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