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Exhibits

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Discuss aggressive respiratory treatment options

Obtain a sputum culture

Monitor the oxygen saturation

Allow the client to take a position of comfort

Wean the supplemental oxygen

Prepare for deep tracheal suctioning

Consider positive pressure ventilation

Discuss with the client potential asthma triggers

Answer and Explanation

Correct Answer : B,C,D,E,H

A. While discussing treatment options is important, it may not be immediately necessary at this point unless the client shows signs of severe respiratory distress or failure.

B. Given the client's respiratory distress and recent cold symptoms, obtaining a sputum culture can help identify any underlying infection, which is important for appropriate treatment, particularly with the prescribed azithromycin.

C. Continuous monitoring of oxygen saturation is essential to ensure that the client's oxygen levels are adequate, especially since she is at risk for hypoxia. The goal is to maintain oxygen saturation greater than 94%.

D. Positioning the client in a way that enhances her comfort, such as sitting upright, can help improve her breathing and reduce respiratory distress. This is a fundamental nursing intervention in respiratory care.

E. If the client's oxygen saturation improves, the nurse can begin to wean the supplemental oxygen while monitoring for any signs of respiratory distress. This step should be approached cautiously to ensure the client maintains adequate oxygen levels.

F. There is no indication that the client requires deep tracheal suctioning at this moment. This action is reserved for patients with excessive secretions or compromised airway patency.

G. Positive pressure ventilation would typically be considered if the client were in severe respiratory distress or failure. The current assessment does not indicate an immediate need for this intervention.

H. Education on potential asthma triggers is crucial for the client's long-term management. This discussion can help the client avoid situations that could lead to future exacerbations, thus improving her overall asthma control.

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

Explanation

A. Obtaining a portable chest x-ray is the gold standard for confirming ETT placement, ensuring the tube is positioned correctly in the trachea and not in the esophagus.

B. Assessing for symmetrical chest movement is important; asymmetry may indicate improper tube placement or lung involvement.

C. Monitoring ETT markings can provide some information about placement, but it is not a definitive method for verifying correct placement since individual anatomy can vary.

D. Auscultating for bilateral breath sounds confirms that air is reaching both lungs, indicating proper ETT placement.

E. Checking capillary refill does not assess ETT placement and is not relevant in this context; the focus should be on respiratory status and tube positioning.

A. Complete blood count B. Serum sodium C. Peak inspiratory flow D. Temperature E. Peak expiratory flow F. Heart rate G. Breath sounds H. Oxygen saturation

Correct Answer is ["C","E","F","G","H"]

Explanation

A. A complete blood count is not immediately relevant after nebulization and does not provide direct information about the respiratory status or treatment effectiveness.

B. Serum sodium levels are not related to the immediate effects of albuterol nebulization and would not provide useful information following the treatment.

C. Assessing peak inspiratory flow can help determine how well the client is able to take in air after the nebulizer treatment. This is an important measure of respiratory function, especially in asthma management.

D. While temperature can be monitored to assess for infection or inflammation, it is not a priority assessment immediately after administering an albuterol nebulizer treatment in this context.

E. Peak expiratory flow is critical to evaluate the effectiveness of the albuterol nebulization. Monitoring this parameter can help assess the improvement in airway obstruction.

F. Albuterol can cause tachycardia as a side effect. Monitoring the heart rate after treatment helps ensure that the client is stable and not experiencing any adverse effects.

G. Assessing breath sounds post-treatment is essential to determine whether there has been an improvement in airway patency and to identify any residual wheezing or other abnormal sounds.

H. Oxygen saturation should be monitored after the treatment to assess the effectiveness of the nebulization in improving oxygenation. It is important to ensure that the saturation levels rise above 94%.

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Exhibits The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

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

Explanation

Exhibits The nurse starts the albuterol nebulizer as prescribed. Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.

Correct Answer is ["C","E","F","G","H"]

Explanation

A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?

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The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

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Exhibits

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Which action(s) should the nurse plan for the rest of the shift? Select all that apply.