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 C
Explanation
Increased anteroposterior diameter of the chest, also known as barrel chest, is a common finding in clients who have COPD with emphysema. It is caused by chronic air trapping and hyperinflation of the lungs, which results in fattening of the diaphragm and widening of the rib cage.
a) Oxygen saturation level 96% is within the normal range of 95% to 100% and does not indicate hypoxemia or impaired gas exchange. Clients who have COPD with emphysema typically have lower oxygen saturation levels, ranging from 88% to 92%.
b) Respiratory alkalosis is a condition in which the blood pH is elevated due to decreased carbon dioxide levels. It is caused by hyperventilation, which can occur in response to hypoxia, anxiety, or pain. Clients who have COPD with emphysema usually have respiratory acidosis, which is a condition in which the blood pH is lowered due to increased carbon dioxide levels. It is caused by hypoventilation, which results from impaired lung function and airway obstruction.
d) Petechiae on chest are small red or purple spots on the skin caused by bleeding from capillaries. They are not a typical finding in clients who have COPD with emphysema, unless they have severe coughing episodes or coagulation disorders. They can indicate infection, inflammation, trauma, or vascular disease.
Correct Answer is A
Explanation
Montelukast is an oral leukotriene receptor antagonist that prevents inflammation and bronchoconstriction in asthma. It is taken once daily in the evening to prevent nocturnal symptoms and improve morning lung function.
- "I rinse my mouth after taking this medication." This is not necessary, as montelukast is not associated with oral thrush or dysgeusia, unlike some inhaled corticosteroids.
- "I use a spacer device when I inhale this medication." This is not applicable, as montelukast is not an inhaler, but a tablet or chewable form.
- "I take this medication when I get an asthma attack." This is not appropriate, as montelukast is not a rescue medication, but a maintenance medication that should be taken regularly to prevent asthma exacerbations. A short-acting beta2 agonist such as albuterol should be used for acute relief of symptoms.
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