A parent brings their child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

Frequency that the child uses a rescue inhaler during the week.

Type of inhaler the child typically uses on a regular basis.

Type of allergen exposure or trigger for the current episode.

Last dose and type of rescue inhaler used by the child.

Answer and Explanation

The Correct Answer is D

A. Frequency that the child uses a rescue inhaler during the week: While it is important to know how often the child uses a rescue inhaler, it does not provide immediate, critical information to assess the severity of the current asthma attack.

B. Type of inhaler the child typically uses on a regular basis: While knowing the type of inhaler the child uses regularly can provide insight into their asthma management, it is not the most critical information at this moment, the current treatment is he most urgent.

C. Type of allergen exposure or trigger for the current episode: Understanding the trigger for the current asthma episode is helpful for long-term management but is not as urgent in the immediate assessment of the child’s condition during an acute exacerbation.

D. Last dose and type of rescue inhaler used by the child: This information helps assess whether the child has received appropriate treatment and whether additional or different interventions are needed immediately to address the asthma exacerbation, helps guide further treatment decisions.

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Correct Answer is A

Explanation

A. Avoid straining at stool, bending, or lifting heavy objects: These activities can increase intraocular pressure and disrupt healing of the surgical site after cataract extraction. The client should be taught to avoid anything that could strain the eye and risk complications like hemorrhage or wound dehiscence.

B. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment:
Routine irrigation is not required and may introduce additional risk. Clients are instructed on proper hand hygiene and drop instillation rather than conjunctival irrigation.

C. Do not read without direct lighting for 6 weeks: While good lighting helps reduce eye strain, reading in lower light does not delay healing after cataract surgery. This instruction is unnecessary and could limit the client’s ability to resume normal activities.

D. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: Although bright light can be uncomfortable post-surgery, wearing sunglasses typically offers sufficient protection. There is no requirement to restrict sunlight exposure completely.

A. Avoid forcing apart the teeth. B. Loosen clothing around the neck. C. Position the head from injury. D. Secure the limbs to the body.

Correct Answer is D

Explanation

A. Avoid forcing apart the teeth: Placing objects in the client’s mouth or trying to pry open the teeth can cause injury. It is important to let the seizure pass without interfering with the jaw or mouth.

B. Loosen clothing around the neck: Loosening tight clothing reduces the risk of airway obstruction or restricted breathing during a seizure. This is a correct and helpful intervention.

C. Position the head from injury: Protecting the client’s head with a soft object prevents trauma during convulsions. This is a recommended and safe practice during seizures.

D. Secure the limbs to the body: Restraining or holding down limbs can cause musculoskeletal injuries and increase agitation. Seizure safety protocols emphasize allowing movement without physical restraint.

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A parent brings their child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing an older adult client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

Correct Answer is A

Explanation

The nurse is teaching a client's family member about seizure precautions. Which action described by the family member indicates the need for additional teaching?

Correct Answer is D

Explanation

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