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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While high serum insulin levels can be indicative of insulin resistance and metabolic syndrome, they are not as directly related to cardiac risk as large waist circumference.
Choice B reason: Hyperpigmentation on neck skin folds, also known as acanthosis nigricans, can indicate insulin resistance and metabolic syndrome but is not as strong a predictor of cardiac disease as central obesity.
Choice C reason: Poor muscle tone is not a direct indicator of cardiac disease risk. It can be associated with overall health and fitness but is not as specific a risk factor for cardiac disease.
Choice D reason: Large waist circumference with central fat, also known as abdominal obesity, is a well-known risk factor for cardiovascular disease. Central fat is associated with increased risk of heart disease, hypertension, and diabetes, making it a significant indicator to monitor.
Correct Answer is B
Explanation
Choice A reason: Denial of urinary frequency, urgency, or dysuria is a good sign of symptom relief but does not directly confirm the success of the lithotripsy in terms of stone removal.
Choice B reason: The presence of stone fragments in the urine after lithotripsy indicates that the procedure successfully broke up the kidney stones, allowing them to be excreted. This is a direct and specific measure of the procedure's effectiveness.
Choice C reason: Pale pink urine with no observable blood clots is a positive sign and suggests that there is no significant bleeding, but it does not directly confirm the removal of the kidney stones.
Choice D reason: Normal serum creatinine and blood urea nitrogen (BUN) levels indicate good kidney function but do not specifically reflect the success of the lithotripsy in breaking up and removing the stones.
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