A nurse in an emergency department is caring for a client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Asthma: The client’s symptoms of wheezing, chest tightness, and persistent dry cough, especially worsening at night, are characteristic of asthma. The presence of bilateral wheezing and a low pulse oximetry reading of 90% indicate that the client is experiencing bronchoconstriction and reduced airflow, which are hallmark features of an asthma exacerbation.
Plan to administer bronchodilator: Administering a bronchodilator is essential in treating asthma as it helps relax the bronchial muscles, leading to bronchodilation and improved airflow. This intervention is crucial for alleviating wheezing and shortness of breath associated with an asthma attack.
Measure the client's peak airflow: Measuring peak airflow using a peak flow meter helps assess the severity of the asthma and the effectiveness of the bronchodilator therapy. It provides objective data on the client’s lung function, allowing the nurse to evaluate changes in the client’s condition over time and make necessary adjustments to the treatment plan.
Prepare to administer an antibiotic: This action is not appropriate for asthma since antibiotics are ineffective against viral conditions and are typically used for bacterial infections such as pneumonia. Since the client is experiencing asthma symptoms rather than an infection, this intervention does not address the underlying problem.
Request a prescription for a diuretic: This action is also not appropriate in this scenario. Diuretics are used to manage fluid overload conditions, such as pulmonary edema or heart failure, and would not be indicated for a client with asthma experiencing wheezing and shortness of breath.
Teach the client pursed lip breathing: This technique is more commonly used in COPD to prevent airway collapse rather than in asthma, where bronchodilators provide more immediate relief.
Oxygen saturation: Monitoring oxygen saturation is critical for assessing the effectiveness of treatment in clients with asthma. A low oxygen saturation level indicates inadequate oxygenation, which necessitates immediate intervention. Tracking this parameter helps ensure the client is receiving adequate oxygen during their treatment.
Pulmonary function tests: While pulmonary function tests are useful for assessing long-term lung function, they provide valuable information on how well the lungs are functioning. Pulmonary function tests (PFTs), including forced expiratory volume in one second (FEV1) and peak expiratory flow rate (PEFR), help evaluate the degree of airway obstruction and response to treatment. Monitoring PFTs over time provides insight into asthma control and treatment effectiveness.
Weight: Monitoring weight is not a primary concern in managing asthma exacerbations. While it can be relevant in certain chronic conditions or for assessing fluid retention, it is not directly related to monitoring respiratory status or the effectiveness of asthma treatment.
Temperature: While it is important to monitor temperature in general to identify potential infections, it is not specifically relevant to assessing asthma status unless there are other indications of an underlying infection contributing to the respiratory symptoms. In the context of asthma management, oxygen saturation and peak airflow are more critical parameters.
Urine output: Monitoring urine output is not a direct indicator of asthma status. It is more relevant in assessing kidney function and fluid balance, which are not primary concerns in the acute management of asthma exacerbations.
COPD typically presents with a long history of smoking, chronic cough, and progressive respiratory symptoms. In this scenario, the client is a nonsmoker, and the acute nature of the symptoms is more indicative of asthma rather than COPD.
Pulmonary edema often presents with symptoms such as cough with frothy sputum, severe shortness of breath, and hypoxia, typically related to heart failure. The client’s symptoms are more consistent with asthma rather than fluid overload.
Pneumonia: Pneumonia usually presents with symptoms such as productive cough, fever, chills, and localized lung findings. While wheezing can occur, the lack of fever and the specific nighttime worsening of symptoms align more closely with asthma than with pneumonia.
Asthma: The client’s symptoms of wheezing, chest tightness, and dry cough, especially worsening at night, are characteristic of asthma. The presence of bilateral wheezing and a low pulse oximetry reading indicate bronchoconstriction and reduced airflow, consistent with an asthma exacerbation.

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Correct Answer is A

Explanation

A. Incentive spirometry: This is the most effective independent nursing measure to prevent atelectasis. Incentive spirometry encourages deep breathing and lung expansion, which helps to keep the alveoli open and reduces the risk of collapse. It is particularly beneficial for clients at risk for atelectasis, such as those who have had surgery, are immobile, or have respiratory issues. Regular use of the incentive spirometer promotes optimal lung function and helps prevent the development of atelectasis.
B. Increase oral fluid intake: While maintaining adequate hydration is important for overall health and can help thin secretions, it is not as directly effective in preventing atelectasis as incentive spirometry. Increased fluid intake alone does not promote deep breathing or lung expansion, which are critical in preventing airway collapse.
C. Ambulation: Although ambulation is an important intervention for promoting overall mobility and respiratory function, it may not be as practical for all clients, especially those who are unable to move independently. While getting the client up and moving can help prevent atelectasis, the most immediate and effective measure remains the use of incentive spirometry, which can be performed regardless of the client’s mobility status.
D. Oxygen therapy: While oxygen therapy can help improve oxygenation in clients with respiratory issues, it does not directly prevent atelectasis. Providing supplemental oxygen does not address the need for lung expansion and deep breathing, which are essential in maintaining alveolar patency. Therefore, oxygen therapy should not be prioritized as the primary independent measure to prevent atelectasis.

A. Conduct a study about the time and money costs of implementing the change. B. Establish a benchmark to identify a standard of performance. C. Compare the number of medication errors before and after the action was implemented. D. Provide the staff with a questionnaire to quantify staff satisfaction with the changes.

Correct Answer is C

Explanation

A. Conduct a study about the time and money costs of implementing the change. While analyzing costs and time efficiency is important for evaluating resource utilization, it does not directly measure the effectiveness of the changes in reducing medication errors. The primary goal of quality improvement is to assess patient safety outcomes rather than financial impact alone.
B. Establish a benchmark to identify a standard of performance. Setting benchmarks is a useful strategy for quality control, but it is a preliminary step in the evaluation process. Benchmarks provide a target for improvement, but they do not measure whether the specific changes implemented have led to a reduction in medication errors.
C. Compare the number of medication errors before and after the action was implemented. The most effective way to evaluate the success of the changes is to analyze pre- and post-intervention data. Comparing the frequency of medication errors before and after the quality improvement measures allows for an objective assessment of whether the interventions have led to a meaningful reduction in errors.
D. Provide the staff with a questionnaire to quantify staff satisfaction with the changes. Staff feedback is valuable for assessing workflow and morale, but it does not directly measure the effectiveness of the intervention in reducing medication errors. A reduction in actual error rates provides a more concrete evaluation of the intervention’s success.

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Explanation

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Correct Answer is C

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