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 C
Explanation
Rebound congestion, also known as rhinitis medicamentosa, is a common adverse effect associated with the prolonged use of nasal decongestants. It occurs when the blood vessels in the nasal passages become dependent on the medication for constriction and lose their ability to regulate naturally. As a result, when the medication wears off, the nasal congestion worsens, leading to a cycle of continued use and worsening symptoms.
In this scenario, the patient's complaint of worsening nasal congestion despite using oxymetazoline every 2 to 4 hours for the past 5 days suggests the possibility of rebound congestion. The nurse should explain to the patient that prolonged or frequent use of nasal decongestants can lead to this effect and recommend gradually tapering off the medication use or discontinuing it altogether. The nurse may also suggest alternative non-medication strategies for managing nasal congestion, such as saline nasal sprays or steam inhalation.
Correct Answer is D
Explanation
Theophylline is a bronchodilator medication used in the treatment of asthma and other respiratory conditions. It works by relaxing the smooth muscles in the airways, allowing for easier breathing. However, theophylline is associated with potential adverse effects, and one of the most significant concerns is its potential to cause dysrhythmias (irregular heart rhythms).
Dysrhythmias can include tachycardia (rapid heart rate), atrial fibrillation, or other disturbances in heart rhythm.
Constipation is not a commonly reported adverse effect of theophylline. Oliguria (decreased urine output) is not typically associated with theophylline use. Drowsiness can occur with theophylline, but dysrhythmias are considered a more significant and potentially serious adverse effect. It is crucial for the nurse to educate the client about the potential for dysrhythmias and advise them to report any irregular heartbeat or other cardiac symptoms promptly.
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