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","C","D"]
Explanation
A. Bradycardia: Emphysema itself is not directly associated with bradycardia. However, severe hypoxia or other complications may lead to changes in heart rate.
B. Barrel chest: Emphysema is characterized by the destruction of alveoli, leading to loss of elastic recoil in the lungs. This results in hyperinflation and an increase in the anteroposterior diameter of the chest, creating a barrel-shaped appearance.
C. Dyspnea: Emphysema causes difficulty in exhaling air due to the loss of elasticity in the lung tissue. This can lead to a feeling of breathlessness.
D. Deep respirations: Clients with emphysema often adopt a pattern of deep and labored breathing to compensate for the decreased efficiency of gas exchange.
E. Clubbing of the fingers: Clubbing of the fingers is more commonly associated with chronic hypoxia, but it is not a typical finding in emphysema. Clubbing can occur in certain lung diseases, but it is not a defining characteristic of emphysema.
Correct Answer is D
Explanation
A. A friction rub:A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.
B. A split second heart sound S₂:A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.
C. The third heart sound (S3):S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.
D. The fourth heart sound (S4):S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.
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