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 C
Explanation
Choice A rationale:
Domestic violence assistance is an important topic, but it falls under secondary and tertiary prevention rather than primary disease prevention, which is the focus of this community outreach program. Primary prevention aims to prevent the disease from occurring in the first place, while domestic violence assistance addresses an existing issue.
Choice B rationale:
Blood pressure screening is valuable for early detection of hypertension, but it also falls under secondary prevention. Primary prevention focuses on preventing the onset of diseases through measures such as immunizations, health education, and lifestyle modifications.
Choice D rationale:
Outreach for support group information is essential for clients with chronic conditions or specific needs. However, it is not primarily related to preventing diseases at the population level, which is the primary goal of this community outreach program. This topic may be more relevant to secondary and tertiary prevention efforts.
Correct Answer is B
Explanation
- A bowel patern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel patern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.
- A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patern. It also includes inspecting and auscultating the abdomen for any abnormalities³.
- When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel patern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may affect the client's bowel function.
Therefore, option B is the correct answer, while options A, C, and D are incorrect.
Option A is incorrect because administering a stool softener without assessing the client's bowel patern may not be appropriate or effective.
Option C is incorrect because encouraging ambulation may help to stimulate bowel activity, but it is not the first action to take.
Option D is incorrect because recommending dietary changes may be helpful for preventing or treating constipation, but it is not the first action to take.
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