A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

Asthma action plans often use a color-coded system to guide management based on peak expiratory flow rate (PEFR) measurements. The zones are typically green (80-100% of personal best), yellow (50-79% of personal best), and red (less than 50% of personal best).

A. The student needs to go to the hospital.

This is not necessarily required when the student is in the yellow zone. The yellow zone indicates caution and the need for intervention, but it does not immediately require hospitalization unless symptoms worsen or do not improve after using the quick-relief inhaler.

B. The nurse should obtain a second expiratory flow rate.

Confirming the peak flow measurement with a second reading ensures accuracy and helps to make informed decisions about the student's asthma management.

C. The student should use his quick-relief inhaler.

In the yellow zone, indicating moderate impairment, the use of a quick-relief (rescue) inhaler is often recommended to relieve symptoms and prevent progression to the red zone.

D. The student's peak flow is 50% to 80% of his best peak flow.

This is the correct range for the yellow zone, indicating moderate impairment. Action is needed to prevent worsening.

E. The student's asthma is not well controlled.

Being in the yellow zone indicates that the asthma is not well controlled and may require adjustments in the long-term management plan, including possible changes to daily controller medications.

A. Tissue integrity: While assessing tissue integrity is important, ensuring airway patency takes precedence in the immediate postoperative period, especially following a procedure involving the larynx. Maintaining a patent airway is a critical priority.

B. Pain severity: Pain assessment is important, but it is not the primary concern immediately postoperatively in the context of a partial laryngectomy. Airway patency is of higher priority.

C. Airway patency: This is the correct answer. Following a partial laryngectomy, there may be concerns related to airway compromise due to the surgical procedure. The nurse should assess the airway first to ensure there are no obstructions or complications affecting the client's ability to breathe.

D. Wound drainage: While assessing wound drainage is important for monitoring surgical sites, it is not the first priority in the immediate postoperative period following a partial laryngectomy. Airway patency is a more critical concern.