A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all that apply.)
The student needs to go to the hospital.
The nurse should obtain a second expiratory flow rate.
The student's peak flow is 50% to 80% of his best peak flow.
The student should use his quick-relief inhaler.
The student's asthma is not well controlled,
Correct Answer : B,C,D,E
Asthma action plans often use a color-coded system to guide management based on peak expiratory flow rate (PEFR) measurements. The zones are typically green (80-100% of personal best), yellow (50-79% of personal best), and red (less than 50% of personal best).
A. The student needs to go to the hospital.
This is not necessarily required when the student is in the yellow zone. The yellow zone indicates caution and the need for intervention, but it does not immediately require hospitalization unless symptoms worsen or do not improve after using the quick-relief inhaler.
B. The nurse should obtain a second expiratory flow rate.
Confirming the peak flow measurement with a second reading ensures accuracy and helps to make informed decisions about the student's asthma management.
C. The student should use his quick-relief inhaler.
In the yellow zone, indicating moderate impairment, the use of a quick-relief (rescue) inhaler is often recommended to relieve symptoms and prevent progression to the red zone.
D. The student's peak flow is 50% to 80% of his best peak flow.
This is the correct range for the yellow zone, indicating moderate impairment. Action is needed to prevent worsening.
E. The student's asthma is not well controlled.
Being in the yellow zone indicates that the asthma is not well controlled and may require adjustments in the long-term management plan, including possible changes to daily controller medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Correct answer: B
A. "I will take my diuretic before sleep and drink fluids during the day": This statement is not correct. Diuretics are usually taken in the morning to avoid disrupting sleep with increased urination at night. Additionally, fluid intake is generally restricted in congestive heart failure to manage fluid balance.
B. "I plan to slow down if I am tired the day after exercising":This statement reflects an understanding of the need to manage activity levels and recognize the signs of overexertion, which is crucial for clients with congestive heart failure. Pacing activities and allowing for adequate rest can help prevent exacerbations of heart failure symptoms.
C. "I will read food labels and limit my sodium to 4 grams per day": This is incorrect. Limiting sodium intake is a key component of heart failure management. The recommended sodium intake for individuals with heart failure is often much lower than 4 grams per day, typically around 2 grams or less.
D. "I should use naproxen to manage discomfort": Using nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen can contribute to fluid retention and worsen heart failure symptoms. This statement is not indicative of effective teaching.
Correct Answer is A
Explanation
A. "These tests help determine the degree of damage to the heart tissues." - This is the correct statement. Cardiac enzyme studies, such as creatine kinase (CK), CK-MB, troponin I, and troponin T, are used to assess the extent of myocardial damage during an acute myocardial infarction (MI). Elevated levels of these enzymes indicate myocardial injury and help healthcare providers determine the severity of the heart tissue damage.
B. "Cardiac enzymes will identify the location of the MI." - While cardiac enzymes can confirm the presence of an MI, they do not specifically identify the location of the infarction. Other diagnostic tools, such as electrocardiogram (ECG) and imaging studies, may help determine the location of the MI.
C. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." - Cardiac enzymes are not used to diagnose pulmonary congestion. Other diagnostic methods, such as chest X-rays and physical examination, are more appropriate for assessing pulmonary congestion.
D. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." - Cardiac enzyme studies do not provide information about the overall heart structure or the mobility of heart valves. Imaging studies, such as echocardiography, are used for this purpose.
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