After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields.
Which action should the nurse take next based on the assessment?
Use a peak flow meter to assess the respiratory status.
Administer a stat dose of corticosteroids.
Document the normal finding in the client's health record.
Repeat a dose of the client's rescue drug.
The Correct Answer is A
Choice A rationale:
Use a peak flow meter to assess the respiratory status. Assessing the client's respiratory status using a peak flow meter is the most appropriate next action after administering albuterol, a bronchodilator. It helps determine the client's lung function and response to the medication. This information guides further interventions and treatment decisions.
Choice B rationale:
Administer a stat dose of corticosteroids. Administering corticosteroids may be indicated in some cases of respiratory distress or exacerbation of asthma. However, it should not be the immediate next step after albuterol administration. Assessing the client's response to albuterol through lung function testing (peak flow) is essential before deciding on additional medications.
Choice C rationale:
Document the normal finding in the client's health record. Documenting normal findings is important for maintaining accurate medical records, but in this case, it is premature. The nurse should first assess the client's response to albuterol and ensure that the respiratory status is indeed normal before documenting the findings.
Choice D rationale:
Repeat a dose of the client's rescue drug. Administering another dose of the rescue drug (albuterol) without assessing the client's response and lung function would not be the most appropriate action. It is essential to determine whether the initial dose was effective before considering additional doses or alternative treatments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
4012 mg/day is not the correct answer. To calculate the maximum safe dosage of valproic acid, you need to convert the client's weight from pounds to kilograms. The client's weight in kilograms can be calculated by dividing the weight in pounds by 2.2. Therefore, 176 pounds divided by 2.2 equals 80 kilograms. The maximum safe dosage is 60 mg/kg/day, so 60 mg multiplied by 80 kg equals 4800 mg/day.
Choice B rationale:
Step 1: Convert the client’s weight from pounds to kilograms. We know that 1 kg is approximately equal to 2.2 pounds. So, we have:
176 pounds ÷ 2.2 = 80 kg (approximately)
Step 2: Calculate the maximum safe dosage for the client. We know that the maximum safe dosage of valproic acid is 60 mg/kg/day. So, we have:
60 mg/kg/day × 80 kg = 4800 mg/day
So, the maximum safe dosage for a client who weighs 176 pounds is4800 mg/day.
Choice C rationale:
3520 mg/day is not the correct answer. It does not accurately calculate the maximum safe dosage based on the client's weight.
Choice D rationale:
6171 mg/day is not the correct answer. It is significantly higher than the correct calculation and would exceed the maximum safe dosage for the client's weight.
Correct Answer is C
Explanation
The correct answer is choicec. Administer prescribed stool softener.
Choice A rationale:
Administering prescribed PRN sleep medications can help the client rest, but it is not the highest priority. Managing pain and preventing complications from the laceration are more critical.
Choice B rationale:
Encouraging the use of prescribed analgesic perineal sprays can help manage pain and promote healing, but it is not as crucial as preventing constipation, which can cause significant discomfort and complications.
Choice C rationale:
Administering prescribed stool softeners is the highest priority because a fourth-degree laceration involves the anal sphincter and rectal mucosa.Preventing constipation is essential to avoid straining during bowel movements, which can cause pain and disrupt the healing process.
Choice D rationale:
Encouraging breastfeeding to promote uterine involution is important for postpartum recovery, but it is not directly related to the care of a fourth-degree laceration. Managing pain and preventing complications from the laceration take precedence.
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