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).

Answer and Explanation

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.

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Correct Answer is B

Explanation

This response is empathetic and therapeutic, as it acknowledges the client's feelings and invites her to express her concerns. It also shows respect and interest in the client's perspective.

a) This response is false reassurance and nontherapeutic, as it dismisses the client's feelings and implies

that the surgery will solve everything.

b) This response is self-disclosure and nontherapeutic, as it shifts the focus from the client to the nurse and

does not address the client's fears.

d) This response is minimizing and nontherapeutic, as it tells the client how to feel and does not acknowledge the client's regret or anxiety.

A. "We'll continue to encourage him to drink lots of ﬂuids." B. "We'll take his temperature every 4 hours." C. "We'll discard his toothbrush and buy another." D. "We'll give him Tylenol for the pain."

Correct Answer is C

Explanation

Discarding the toothbrush and buying another is a way to prevent disease transmission, as the toothbrush can harbor bacteria and reinfect the child or spread the infection to others. The toothbrush should be discarded after 24 hours of antibiotic therapy.

a) Encouraging the child to drink lots of ﬂuids is a way to promote hydration and soothe the throat, but it does not prevent disease transmission. The child should avoid sharing cups or utensils with others and use disposable tissues or paper towels.
b) Taking the child's temperature every 4 hours is a way to monitor fever, but it does not prevent disease transmission. The thermometer should be cleaned and disinfected after each use and not shared with others.
d) Giving the child Tylenol for the pain is a way to relieve discomfort, but it does not prevent disease transmission. The medication should be administered according to the label instructions and not shared with others.

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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?

Nursing Test Bank

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