A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?
Determine the cause of the acute exacerbation.
Obtain a peak flow reading.
Administer an inhaled glucocorticoid.
Administer a short-acting beta2-agonist (SABA).
The Correct Answer is D
Administering a short-acting beta2-agonist (SABA), such as albuterol, is the priority intervention for the nurse to take, as it provides rapid bronchodilation and relieves bronchospasm, which are the main features of status asthmaticus. Status asthmaticus is a severe and life-threatening asthma attack that does not respond to usual treatment and requires immediate medical attention.
a) Determining the cause of the acute exacerbation is important, but not the priority intervention for the nurse to take. The cause may be an allergen, infection, stress, or exercise, but it does not affect the immediate management of status asthmaticus. The nurse should focus on restoring airway patency and oxygenation first, and then identify and avoid triggers later.
b) Obtaining a peak flow reading is important, but not the priority intervention for the nurse to take. The peak flow reading measures the maximum expiratory flow rate and indicates the degree of airway obstruction. However, it may not be feasible or accurate in a child who is experiencing status asthmaticus, as they may be too dyspneic or agitated to perform the test. The nurse should rely on other signs of respiratory distress, such as wheezes, retractions, cyanosis, or pulse oximetry.
c) Administering an inhaled glucocorticoid is important, but not the priority intervention for the nurse to take. Glucocorticoids, such as fluticasone or budesonide, reduce inflammation and mucus production in the airways, but they have a delayed onset of action and are not effective for acute asthma attacks. They are used for long-term control and prevention of asthma symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Pursed-lip breathing is a technique that helps clients with COPD to exhale more effectively and prevent air trapping in the lungs. It also reduces dyspnea and improves oxygenation.
a) A low protein diet is not recommended for clients with COPD, as they need adequate protein intake to maintain muscle mass and prevent malnutrition.
c) Fluid restriction is not necessary for clients with COPD, unless they have signs of fluid overload or heart failure. Adequate hydration helps to thin secretions and facilitate expectoration.
d) Early-morning hours are not the best time for exercise and activity for clients with COPD, as they may experience more shortness of breath and fatigue due to diurnal variations in lung function. A better time would be mid-morning or afternoon, after taking bronchodilators and clearing secretions.
Correct Answer is ["100"]
Explanation
To calculate the infusion rate, use the formula:
mL/hr = (volume of solution in mL / time of infusion in hr) x 60 min/hr
Plug in the given values:
mL/hr = (50 mL / 0.5 hr) x 60 min/hr
Simplify and solve:
mL/hr = 100 x 60 min/hr
mL/hr = 100 mL/hr
Round to the nearest whole number and add a leading zero if needed:
mL/hr = 100 mL/hr
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