After initializing a steroid nebulizer treatment for an asthmatic client in respiratory distress, which intervention is most important for the nurse to implement?

Elevate the head of the bed to 90 degrees.

Monitor pulse oximetry every 2 hours.

Determine exposure to asthmatic triggers.

Teach proper use of a rescue inhaler.

Answer and Explanation

The Correct Answer is A

Choice A reason: Elevating the head of the bed to 90 degrees is crucial for clients in respiratory distress. This position helps to maximize lung expansion, improve breathing, and alleviate respiratory effort. It provides immediate support to enhance oxygenation and ventilation.

Choice B reason: Monitoring pulse oximetry is important for assessing the client's oxygenation status but should be done continuously rather than every 2 hours in a client in respiratory distress.

Choice C reason: Determining exposure to asthmatic triggers is relevant for long-term management but not the immediate priority in an acute situation where the client is in respiratory distress.

Choice D reason: Teaching the proper use of a rescue inhaler is essential but should be done after stabilizing the client's condition. The immediate focus should be on interventions that provide rapid relief from respiratory distress.

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Correct Answer is ["0.4"]

Explanation

Step 1: Determine the concentration of enoxaparin. 60 mg is equivalent to 0.6 mall

Step 2: Set up the ratio to find how many mL corresponds to 40 mg. (40 mg) ÷ (60 mg) = x ÷ (0.6 mL)

Step 3: Solve for x. x = (40 mg) × (0.6 mL) ÷ (60 mg) x = 24 ÷ 60 x = 0.4 mL

So, the nurse should administer 0.4 mL

A. Jugular vein distention. B. Bilateral basilar crackles. C. 3+ pitting enema in the ankles. D. Hepatomegaly with right upper quadrant (RUQ) tenderness.

Correct Answer is B

Explanation

Choice A reason: Jugular vein distention is more commonly associated with right ventricular heart failure, as it indicates increased central venous pressure.

Choice B reason: Bilateral basilar crackles are a hallmark sign of left ventricular heart failure. They occur due to pulmonary congestion and enema, resulting from the left ventricle's inability to effectively pump blood out to the body, causing fluid to back up into the lungs.

Choice C reason: 3+ pitting enema in the ankles is more characteristic of right ventricular heart failure, where fluid accumulates in the peripheral tissues.

Choice D reason: Hepatomegaly with right upper quadrant (RUQ) tenderness is also more indicative of right ventricular heart failure, as it reflects congestion in the liver due to increased venous pressure.

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After initializing a steroid nebulizer treatment for an asthmatic client in respiratory distress, which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a prescription for enoxaparin 40 mg subcutaneous (sub) daily. Enoxaparin is available in a pre-filled cartridge labelled, "60 mg per 0.6 mall" How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.4"]

Explanation

The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this client most likely to exhibit?

Correct Answer is B

Explanation

When assessing a client on the first postoperative day following abdominal surgery, the nurse does not hear any bowel sounds. In response to this finding, which action should the nurse implement?

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