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.
Apply a nonrebreather oxygen mask.
Increase oxygen flow.
Raise the head of the bed.
Take and monitor vital signs.
Administer additional nebulizer treatment as prescribed.
Provide client incentive spirometer and instruct on use
Correct Answer : A,B,C,D,E
A. Apply a nonrebreather oxygen mask. This will help increase the oxygen concentration delivered to the client's lungs and improve oxygen saturation.
B. Increase oxygen flow. Increasing the oxygen flow rate can help to further improve oxygen delivery.
C. Raise the head of the bed. This can help improve lung expansion and facilitate breathing.
D. Take and monitor vital signs. This will help assess the client's response to interventions and identify any deterioration.
E. Administer additional nebulizer treatment as prescribed. If the client's symptoms are not improving, additional nebulizer treatments may be necessary.
F. Provide client incentive spirometer and instruct on use: While incentive spirometry can be helpful in preventing atelectasis, it is not a priority in this acute situation where the client's immediate need is to improve oxygenation and reduce airway obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hemoglobin levels can indicate anemia but are not directly related to the presence of petechiae and ecchymosis, which suggest bleeding issues.
B. The red blood cell count is also important for understanding anemia but does not specifically address the bleeding disorders indicated by the client’s symptoms.
C. The white blood cell count provides information on the immune status but does not relate to bleeding manifestations.
D. The platelet count is critical to assess because petechiae and ecchymosis can be indicative of thrombocytopenia (low platelet count), which can lead to increased bleeding tendencies. Monitoring platelet levels will help determine the cause of these symptoms.
Correct Answer is D
Explanation
A. Administering aspirin is not appropriate at this time, as it may delay treatment for a stroke if that is the underlying cause.
B. Maintaining elevated positioning of the dependent joints is not a priority in this acute situation and does not address the immediate needs of the client showing signs of possible stroke.
C. Verifying laboratory tests like prothrombin time and platelet count is important but is not an immediate intervention that addresses the acute condition.
D. Starting two large bore IV catheters and reviewing criteria for IV fibrinolytic therapy is crucial because the client presents with signs of a potential stroke. Rapid identification and treatment are essential to improving outcomes in acute ischemic stroke cases.
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