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).

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Temperature of 36.1°C (97.0°F) is below normal range and not indicative of organ rejection. Organ rejection often presents with elevated temperature due to the inflammatory response of the immune system attacking the transplanted organ.

Choice B rationale

Weight loss is not a common sign of acute organ rejection. Usually, fluid retention and associated weight gain can occur due to decreased kidney function.

Choice C rationale

Oliguria (reduced urine output) is a primary sign of kidney transplant rejection. It indicates that the transplanted kidney is not functioning properly, which is a critical indicator of rejection.

Choice D rationale

Insomnia is not typically associated with organ rejection. It can be related to stress or other factors but is not a direct sign of rejection.

A. Bubbling of the water in the water seal chamber with exhalation. B. Eyelets are not visible. C. Movement of the trachea toward the unaffected side. D. Crepitus in the area above and surrounding the insertion site.

Correct Answer is C

Explanation

Choice A rationale

Bubbling in the water seal chamber with exhalation indicates that air is still being removed from the pleural space, which is expected with a pneumothorax and is not a cause for immediate concern.

Choice B rationale

Eyelets not being visible indicate that the chest tube is properly placed within the pleural space, not an urgent issue.

Choice C rationale

Movement of the trachea towards the unaffected side is a sign of tension pneumothorax, which requires immediate intervention as it can compromise respiratory function.

Choice D rationale

Crepitus in the area above and surrounding the insertion site indicates subcutaneous emphysema, which can occur but does not necessitate immediate provider notification unless severe.

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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?

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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?