Exhibits

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Take and monitor vital signs.

Administer additional nebulizer treatment.

Increase oxygen flow rate.

Raise the head of the bed.

Provide client with a spirometer for use.

Answer and Explanation

Correct Answer : B,C,D

Choice A reason: Monitoring vital signs is crucial to assess the client's current condition and detect any further deterioration. Changes in vital signs can indicate the effectiveness of the treatment and whether additional interventions are needed. For instance, if the heart rate continues to rise or oxygen saturation drops further, it suggests that the client's condition is worsening and requires immediate attention. Keeping a close eye on the vital signs helps the healthcare team to make timely decisions and adjust the treatment plan as necessary.

Choice B reason: Administering additional nebulizer treatment is necessary because the client is still experiencing shortness of breath and bilateral wheezes even after the initial medication. Nebulizer treatments, such as those containing albuterol and ipratropium, help to relax and open the airways, making breathing easier. Given the client's severe asthma symptoms and the fact that the previous doses were not completely effective, additional treatment can provide the needed relief and prevent further respiratory distress.

Choice C reason: Increasing the oxygen flow rate is essential to improve the client's oxygen saturation levels. The current oxygen saturation of 91% indicates hypoxemia, which can lead to severe complications if not addressed promptly. By increasing the flow rate, the client can receive a higher concentration of oxygen, helping to maintain adequate oxygenation of tissues and organs. Continuous monitoring of oxygen saturation is also important to ensure that the increased flow rate is effective and to make further adjustments if needed.

Choice D reason: Raising the head of the bed helps to facilitate easier breathing for the client. This position allows gravity to assist in the expansion of the lungs and reduces the pressure on the diaphragm, making it easier for the client to take deeper breaths. It also helps to reduce the work of breathing and can be particularly beneficial for clients experiencing respiratory distress. Ensuring that the client is in a comfortable and optimal position for breathing is an important aspect of asthma management.

Choice E reason: While providing a spirometer can be useful for lung function exercises, it is not the immediate priority in this acute situation. The client's primary concern is to stabilize their breathing and ensure adequate oxygenation. Once the client is stable, a spirometer can be introduced as part of long-term management and rehabilitation to improve lung function and monitor progress.

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Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Reviewing written and verbal instructions for a reduced sodium diet is not directly related to the management of primary open-angle glaucoma (POAG). While a healthy diet can contribute to overall well-being, dietary sodium does not have a significant impact on intraocular pressure or glaucoma management. Therefore, this intervention does not directly address the client's primary condition of POAG.

Choice B reason: Teaching strategies for aseptic administration of the eye drops is a critical intervention for clients with POAG. Proper administration of ophthalmic drops is essential to avoid contamination and infection. Aseptic techniques include washing hands before administering the drops, avoiding touching the dropper tip to any surface (including the eye), and ensuring that the dropper cap is replaced tightly after use. These measures help maintain the sterility of the medication and prevent complications such as eye infections, which can exacerbate the client's condition.

Choice C reason: Describing how the use of the eye drops will help improve peripheral vision is not entirely accurate in the context of POAG. The primary goal of ophthalmic drops for POAG is to lower intraocular pressure and prevent further damage to the optic nerve, thereby preserving the remaining vision. These drops do not typically improve peripheral vision that has already been lost. Educating the client with accurate information about the purpose and benefits of the drops helps set realistic expectations and encourages adherence to the treatment regimen.

Choice D reason: Teaching the client to apply pressure over the inner eye corner (punctal occlusion) after administering eye drops is an important intervention. Punctal occlusion helps prevent the medication from draining into the tear duct and being absorbed systemically. This technique increases the contact time of the medication with the eye, enhancing its effectiveness and reducing potential systemic side effects. Clients should be instructed to gently press the inner corner of the eye for a few minutes after instilling the drops to ensure maximum benefit.

Choice E reason: Explaining the need to continue eye drops for the rest of their life is essential for clients with POAG. Glaucoma is a chronic condition that requires lifelong management to control intraocular pressure and prevent progression of the disease. Discontinuing the medication can lead to elevated intraocular pressures and irreversible vision loss. Clients should understand the importance of adherence to their prescribed treatment regimen and the lifelong commitment to managing their condition to preserve their vision and quality of life.

A. Massage therapy. B. Structured exercise. C. Carnivore diet. D. Leg elevation.

Correct Answer is B

Explanation

Choice A reason: Massage therapy can help with relaxation and improving circulation in some cases, but it is not a primary intervention for managing PAD. Structured exercise is more effective in improving symptoms and overall cardiovascular health.

Choice B reason: Structured exercise is the most appropriate intervention for a client with PAD. Regular physical activity, especially walking, can help improve blood flow, reduce symptoms, and enhance overall cardiovascular health. It is recommended that clients with PAD engage in a supervised exercise program to ensure safety and effectiveness.

Choice C reason: A carnivore diet is not recommended for clients with PAD. A heart-healthy diet that includes a variety of fruits, vegetables, whole grains, lean proteins, and healthy fats is more beneficial for managing PAD and reducing cardiovascular risk factors.

Choice D reason: Leg elevation can help reduce swelling and improve comfort, but it is not a primary intervention for managing PAD. Structured exercise has a more significant impact on improving blood flow and reducing symptoms.

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Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D","E"]

Explanation

A nurse is developing home care instructions for a client with peripheral artery disease (PAD). Which intervention should the nurse include?

Correct Answer is B

Explanation

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Exhibits

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.