Exhibits
The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, which action(s) should the nurse anticipate? Select all that apply.
Administer medications as prescribed.
Ask the client for a list of current medications.
Notify the healthcare provider of the client's need for intubation.
Apply oxygen via nasal cannula.
Provide client teaching.
Place the client in Trendelenburg position.
Correct Answer : A,D,E
A. Administer medications as prescribed. This includes the albuterol/ipratropium nebulizer treatment and oral prednisone, which are essential for managing acute asthma exacerbations.
B. Ask the client for a list of current medications: While this information is important, it is not the immediate priority in managing an acute asthma exacerbation.
C. Notify the healthcare provider of the client's need for intubation: Intubation is a more invasive procedure and is typically reserved for severe cases of respiratory distress that are not responding to medical therapy. In this case, the client's condition is not severe enough to warrant immediate intubation.
D. Apply oxygen via nasal cannula. The client's oxygen saturation is below 94%, indicating hypoxemia, and supplemental oxygen is necessary to improve oxygenation.
E. Provide client teaching. This includes educating the client about asthma triggers, medication adherence, and early signs of an asthma exacerbation.
F. Place the client in Trendelenburg position: This position is not indicated for asthma exacerbations. It is typically used for conditions like shock or hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Inflammation occurs when uric acid crystals are deposited in the joints, causing the body to react with an inflammatory response.
Pain is a hallmark symptom of an acute gout attack due to the inflammation and the sharp uric acid crystals irritating the joint tissues.
Correct Answer is []
Explanation
Potential Condition
- Dilated Cardiomyopathy: This condition is most likely because the client presents with symptoms of heart failure (chest pain, dizziness, inspiratory crackles, systolic murmur, and ankle edema) alongside a history of hypertension, which can contribute to the development of dilated cardiomyopathy.
Actions to Take
1. Apply Oxygen: The client is showing signs of potential heart failure, and oxygen can help alleviate symptoms associated with decreased oxygenation.
2. Perform 12-lead EKG: An EKG will provide information about any potential cardiac abnormalities, especially in the presence of chest pain and systolic murmur.
Parameters to Monitor
1. Blood Pressure: It is essential to monitor blood pressure due to the client's hypertension and heart failure symptoms, which may be exacerbated by elevated blood pressure.
2. Urine Output: Monitoring urine output helps assess kidney perfusion and fluid status, which can be affected by heart failure and hypertension, particularly in cases of cardiomyopathy.
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