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 C

Explanation

Choice A reason: Notifying the charge nurse that the client will need assignment to the COVID-19 specified area of the facility is an important action for infection control. However, the most immediate priority is to protect oneself and others by maintaining appropriate distance and using PPE.

Choice B reason: Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is necessary for safe specimen handling and to prevent contamination. While important, it follows after ensuring that proper PPE is used and distancing measures are maintained.

Choice C reason: Maintaining a 6 feet (1.8 meters) distance from the client unless wearing an N95 respirator and personal protective equipment (PPE) for droplet precautions is the most crucial action. This step ensures the nurse’s safety and reduces the risk of virus transmission. Proper PPE and distancing protocols are essential in managing a suspected COVID-19 case.

Choice D reason: Starting an intravenous infusion for an antiviral drug to be administered for positive COVID-19 test results is part of the treatment plan if the test comes back positive. However, this step comes after ensuring safety through proper use of PPE and maintaining distance from the client.

A. Client denies urinary frequency, urgency, or dysuria. B. Stone fragments are collected when straining the client's urine. C. Urine is pale pink with no observable blood clots. D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.

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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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 to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is C

Explanation

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

Correct Answer is B

Explanation

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements?

The nurse administers regular insulin SUBQ at 0700 to a client with type 1 diabetes mellitus (DM), after which the client eats one-half of the breakfast provided. At 1000, the client reports being hungry. Which action should the nurse implement?

The nurse calculates the body mass index (BMI) for an adult client who is obese. Which additional assessment finding places the client at high risk for cardiac disease?

The nurse plans to provide diet instructions to a client who was recently diagnosed with diverticulosis. Which dietary modification should the nurse include in the teaching plan?

While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

A client with a history of emphysema and heart failure is admitted to the emergency department with enema, coughing, and shortness of breath. The client's laboratory value for brain natriuretic peptide is elevated. Which prescription is most important for the nurse to implement?

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?