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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","G"]
Explanation
Choice A reason:
Infection prevention is crucial in managing appendicitis. Administering preoperative antibiotics, such as cefazolin, helps prevent surgical site infections and other complications. This aligns with standard care protocols for appendicitis patients.
Choice B reason:
Relieving acute pain is a priority in appendicitis care. Administering analgesics, including opioids, acetaminophen, and NSAIDs, effectively manages pain and reduces inflammation. Providing distraction techniques can also help alleviate discomfort until pain relief is achieved.
Choice C reason:
Client education about the diagnosis and plan of care is essential. Informing the patient about appendicitis, the surgical procedure, and postoperative expectations reduces anxiety and promotes cooperation. Effective communication enhances patient outcomes and satisfaction.
Choice D reason:
Effective coping with illness-related anxiety is important. Providing emotional support and addressing concerns can help the patient manage anxiety associated with the diagnosis and impending surgery. This approach contributes to overall well-being and recovery.
Choice G reason:
Fluid volume management is vital in appendicitis care. Administering intravenous fluids, such as Ringer's lactate, maintains hydration, supports renal function, and prepares the patient for surgery. Proper fluid balance is essential for optimal physiological function.
Correct Answer is B
Explanation
Choice A reason: This option has some errors in the text. The correct explanation should note that carbidopa-levodopa does help reduce the tremors caused by Parkinson's disease, but it primarily works by increasing dopamine levels rather than by assisting other medications. The choice does not clearly state the main mechanism of action of carbidopa-levodopa.
Choice B reason: Carbidopa-levodopa is a combination drug used to treat symptoms of Parkinson's disease. Levodopa is converted into dopamine in the brain, helping to replenish the depleted dopamine levels. Carbidopa helps to prevent the breakdown of levodopa before it reaches the brain. This increases the amount of dopamine available, which is crucial for muscle function and reducing symptoms like tremors and rigidity.
Choice C reason: This option is incorrect because carbidopa-levodopa does not work by reducing inflammation. Instead, it focuses on restoring the balance of dopamine in the brain. Parkinson's disease is primarily a neurodegenerative disorder, not an inflammatory one, so this explanation does not align with the drug's mechanism of action.
Choice D reason: This option is also incorrect as it suggests that carbidopa-levodopa works by slowing the degeneration of the myelin sheath. Parkinson's disease involves the loss of dopamine-producing neurons, not the degeneration of myelin. Therefore, this explanation does not accurately reflect the drug's purpose or mechanism.
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