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?
Obtain a peak flow reading.
Administer an inhaled glucocorticoid.
Determine the cause of the acute exacerbation.
Administer a short-acting B2-agonist (SABA).
The Correct Answer is D
Choice A rationale
Obtaining a peak flow reading provides information about the severity of asthma, but it is not the immediate priority during an acute exacerbation.
Choice B rationale
Administering an inhaled glucocorticoid can help in managing inflammation, but it takes time to work and is not the immediate priority.
Choice C rationale
Determining the cause of the acute exacerbation is important for long-term management but is not the immediate priority.
Choice D rationale
Administering a short-acting B2-agonist (SABA) is the priority because it provides rapid bronchodilation, helping to alleviate the airway obstruction quickly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","F","G","H"]
Explanation
Choice A rationale:
The Glasgow Coma Scale score has decreased from 14 to 12, indicating a decline in the client's level of consciousness. This finding requires immediate attention as it may signify worsening neurological status or an underlying condition such as metabolic disturbances, hypoxia, or intracranial pathology.
Choice C rationale:
The bicarbonate level is 13 mEq/L, which is significantly lower than the normal range of 21-28 mEq/L. This indicates metabolic acidosis, a condition where the blood is too acidic. It requires immediate intervention to prevent severe complications such as shock or organ failure.
Choice F rationale:
The client's blood pressure readings show hypotension with a supine blood pressure of 100/70 mm Hg and sitting blood pressure of 85/50 mm Hg. This suggests hemodynamic instability, which could be due to dehydration, sepsis, or other critical conditions requiring urgent treatment.
Choice G rationale:
The ECG findings indicate tachycardia with a prolonged PR interval, widened QRS complex, and peaked T waves. These are signs of hyperkalemia, a potentially life-threatening condition requiring immediate attention to prevent cardiac arrest.
Choice H rationale:
The sodium level is 152 mEq/L, which is higher than the normal range of 136-145 mEq/L, indicating hypernatremia. This electrolyte imbalance can lead to severe neurological symptoms and requires prompt correction to prevent complications such as seizures or coma.
Correct Answer is A
Explanation
Choice A rationale
Obtaining an influenza vaccine annually is crucial for individuals with type 1 diabetes to reduce the risk of infections that can exacerbate their condition.
Choice B rationale
Injecting insulin in the deltoid muscle is not standard practice as subcutaneous tissue in the abdomen or thigh is preferred for insulin absorption.
Choice C rationale
Administering glucagon is for hypoglycemia, not hyperglycemia; insulin or other medications manage hyperglycemia.
Choice D rationale
Taking glyburide is not suitable for type 1 diabetes as it requires insulin management. .
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