A nurse instructs a 60-year-old client diagnosed with asthma about using a peak expiratory flow meter. Which immediate action should the nurse recommend to the client that obtains a reading of 82% on their peak flow meter?

Go to the emergency department

Continue to use salmeterol and fluticasone as prescribed

Administer an additional rescue dose of Albuterol

Call the physician

Answer and Explanation

The Correct Answer is C

A) Go to the emergency department:
An immediate trip to the emergency department is generally not required for a peak expiratory flow rate (PEFR) of 82%. The PEFR of 82% indicates that the client’s airflow is reduced, but it is not necessarily an emergency. PEFR readings are typically classified into zones: green (80-100% of personal best), yellow (50-79% of personal best), and red (below 50% of personal best). A reading of 82% is in the yellow zone, which suggests that the client is experiencing some degree of airway obstruction or worsening asthma symptoms

B) Continue to use salmeterol and fluticasone as prescribed:
While salmeterol (a long-acting beta agonist) and fluticasone (a corticosteroid) are important for long-term asthma control, continuing their use without additional intervention is not the most appropriate action when the PEFR is 82%. A PEFR of 82% indicates that the client’s asthma is not well controlled at the moment, and the nurse should recommend additional short-acting relief to help open the airways (e.g., a rescue inhaler like albuterol.

C) Administer an additional rescue dose of Albuterol:
The correct immediate action is to administer a rescue dose of albuterol. Albuterol is a short-acting beta-agonist that helps open the airways quickly during an asthma exacerbation. A PEFR of 82% falls in the yellow zone, suggesting some obstruction but not an emergency situation. In this case, administering an additional rescue dose of albuterol can help improve airflow and bring the PEFR closer to normal.

D) Call the physician:
While it may be necessary to call the physician if the client’s asthma symptoms do not improve after using a rescue inhaler or if there is a significant decline in symptoms, the first immediate action should be to use a rescue medication like albuterol. Calling the physician may be appropriate after assessing the response to the rescue medication, but it is not the first step in managing a PEFR of 82%.

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Correct Answer is C

Explanation

A) Retake the vital signs:
While taking vital signs is important, the client’s vital signs (respiratory rate of 13 bpm, oxygen saturation of 92%, and normal skin color) suggest that there is no immediate crisis, such as a sudden drop in oxygen saturation or significant hemodynamic instability. Therefore, retaking the vital signs would not address the most urgent issue at the moment, which is the client's shortness of breath while laying down.

B) Call the healthcare provider:
Calling the healthcare provider may eventually be necessary if the patient's condition worsens or remains unrelieved after interventions. However, the first priority should be to manage the client’s immediate symptoms and improve their comfort. The client’s complaint of shortness of breath when lying down suggests that the positioning may be a contributing factor to their discomfort.

C) Place the client in Fowler's position:
The most appropriate first action for a client with end-stage COPD and shortness of breath while lying down is to place the client in Fowler's position. This position (sitting upright, typically at a 45-60° angle) helps to improve lung expansion and reduce the workload of breathing by using gravity to assist in lung ventilation. It also promotes diaphragmatic breathing, which can relieve the feeling of breathlessness.

D) Increase the oxygen rate:
The client is already on 6 liters of oxygen via nasal cannula and has an oxygen saturation of 92%, which is within an acceptable range for a patient with COPD. Increasing the oxygen rate further could risk causing oxygen toxicity or lead to CO2 retention in clients with COPD, as their respiratory drive is often driven by low oxygen levels rather than high carbon dioxide levels. Thus, increasing the oxygen rate should be done cautiously and only if clinically indicated by a healthcare provider.

A. Peaked T waves B. Inverted P waves C. Widened QRS D. Prominent U wave

Correct Answer is A

Explanation

A) Peaked T waves:
Peaked T waves are a classic sign of hyperkalemia on an EKG. As potassium levels rise, the T waves become taller, more pointed, and narrow, indicating changes in the heart's electrical conduction. This is one of the earliest and most characteristic EKG changes seen with hyperkalemia. Hyperkalemia can result from conditions such as kidney dysfunction, use of potassium-sparing diuretics, or other electrolyte imbalances.

B) Inverted P waves:
Inverted P waves typically suggest issues such as atrial ischemia or ectopic atrial rhythms but are not a hallmark sign of hyperkalemia. They may also appear with other conditions, like atrial fibrillation or atrial flutter. However, inverted P waves are not typically linked to elevated potassium levels.

C) Widened QRS:
A widened QRS complex can occur in several conditions, including hyperkalemia, but it is generally seen in more severe cases. As potassium levels rise further, the QRS complex may widen due to delayed conduction through the ventricles. Although a widened QRS can indicate hyperkalemia, it is a later sign, and it typically occurs after more specific changes like peaked T waves.

D) Prominent U wave:
Prominent U waves are more often associated with hypokalemia (low potassium levels) rather than hyperkalemia. U waves are typically seen after the T wave on the EKG and can be more prominent in conditions of low potassium.

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A nurse instructs a 60-year-old client diagnosed with asthma about using a peak expiratory flow meter. Which immediate action should the nurse recommend to the client that obtains a reading of 82% on their peak flow meter?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is reviewing the EKG strip of a client who is hypertensive and is complaining of muscle weakness. Which of the following abnormalities on the clients EKG should the nurse interpret as a sign of hyperkalemia?

Correct Answer is A

Explanation

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