A nurse is collecting data from a client who has asthma with exacerbation. The client has diminished breath sounds and is using accessory muscles with respirations. Which of the following actions should the nurse take first?
Administer a short-acting bronchodilator.
Reinforce the importance of using a peak flow meter.
Encourage the client to take slow, deep breaths.
Request a prescription for ABGS.
The Correct Answer is A
A. Administer a short-acting bronchodilator: Diminished breath sounds and use of accessory muscles indicate severe airway obstruction and impending respiratory compromise. Administering a short-acting bronchodilator, such as albuterol, provides rapid relief by relaxing bronchial smooth muscle, improving airflow, and preventing further hypoxemia.
B. Reinforce the importance of using a peak flow meter: While peak flow monitoring is useful for long-term asthma management and early detection of exacerbations, it does not address acute airway obstruction. Education about peak flow is important but not the first action in a potentially life-threatening exacerbation.
C. Encourage the client to take slow, deep breaths: Breathing techniques may support ventilation in mild exacerbations, but they cannot relieve severe bronchospasm or restore adequate airflow in a client with diminished breath sounds. This intervention is secondary to urgent pharmacologic management.
D. Request a prescription for ABGs: Arterial blood gas measurement helps assess oxygenation and acid-base status, but it does not immediately reverse airway obstruction. While ABGs may be indicated for evaluation, the first priority is to administer a bronchodilator to relieve life-threatening bronchospasm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Consumes foods with purines: Dietary habits may be relevant for certain conditions, such as gout, but consumption of purine-rich foods is not part of the client’s medical history. It is considered current lifestyle information rather than past or ongoing medical diagnoses.
B. Hospitalized for bipolar disorder 2 years ago: Previous hospitalizations for psychiatric conditions are a key component of the client’s medical history. This information provides context for current mental health status, risk assessment, and planning of care, and helps identify patterns in symptom management and treatment response.
C. Step-sister has major depressive disorder: Family history is important and documented separately under genetic or familial risk factors. While it informs potential predisposition, it does not constitute the client’s personal medical history.
D. Plans to start group therapy sessions once per week: Future intentions or planned interventions reflect care planning and goals rather than historical medical data. This information is documented in the plan of care rather than the medical history section.
Correct Answer is C
Explanation
A. Secure nonwashable items in a plastic bag for 7 days: While isolating nonwashable items can help reduce the risk of lice transmission, lice typically survive only 1–2 days off the scalp. Seven days is longer than necessary, making this measure less practical and not the primary recommendation for controlling pediculosis in the home.
B. Soak combs and brushes in a peroxide and water solution for 2 hr: Lice and nits can be effectively removed from combs and brushes using hot water rather than chemical solutions. Prolonged soaking in peroxide is unnecessary and may damage items without significantly improving decontamination.
C. Machine wash bed sheets in water greater than 54.4° C (130° F): Washing linens, clothing, and towels in hot water effectively kills lice and nits, preventing reinfestation. Heat is the most reliable method for decontaminating items that have been in contact with an infested individual, making this the recommended action.
D. Dry washed clothing and towels in a hot dryer for 10 min: While using a dryer can help, the duration and temperature must be sufficient to kill lice and nits. Ten minutes may be inadequate for thick items, and washing in hot water remains the primary and most effective preventive measure.
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