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Following the administration of albuterol and the subsequent assessment, what actions should the nurse plan for the rest of the shift?

Monitor the oxygen saturation

Prepare for deep tracheal suctioning

Discuss potential asthma triggers with the client

Obtain a sputum culture

Consider positive pressure ventilation

Allow the client to take a position of comfort

Discuss aggressive respiratory treatment options

Wean the supplemental oxygen .

Answer and Explanation

Correct Answer : A,C,F,H

Choice A rationale

Monitoring the oxygen saturation is an important nursing intervention following the administration of albuterol. Albuterol is a bronchodilator and should improve oxygen saturation by increasing airflow and oxygen delivery.

Choice B rationale

Deep tracheal suctioning is not typically required following the administration of albuterol unless the patient has excessive secretions or difficulty clearing secretions.

Choice C rationale

Discussing potential asthma triggers with the client is an important nursing intervention. Understanding and avoiding triggers can help prevent future asthma exacerbations.

Choice D rationale

Obtaining a sputum culture is not typically required following the administration of albuterol unless there is a suspicion of a respiratory infection.

Choice E rationale

Positive pressure ventilation is not typically required following the administration of albuterol unless the patient is in severe respiratory distress.

Choice F rationale

Allowing the client to take a position of comfort can help improve breathing and should be encouraged.

Choice G rationale

Discussing aggressive respiratory treatment options is not typically required following the administration of albuterol unless the patient’s condition is not improving or worsening.

Choice H rationale

Weaning the supplemental oxygen may be appropriate following the administration of albuterol if the patient’s oxygen saturation has improved.

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

Explanation

Choice A rationale

A boggy fundus refers to an enlarged, soft, and tender uterus identified during physical examination. It is most commonly caused by uterine atony or adenomyosis. A boggy fundus 1 cm above the umbilicus requires immediate follow-up as it indicates that the uterus is not contracting properly after childbirth, which can lead to postpartum hemorrhage.

Choice B rationale

A fundus rotated to the right could indicate a distended bladder. This requires immediate follow-up as it can lead to urinary retention and other complications.

Choice C rationale

Voiding 200 mL of clear yellow urine is a normal finding and does not require immediate follow-up.

Choice D rationale

A blood pressure of 90/62 mm Hg is considered normal according to the American Heart Association. Therefore, it does not require immediate follow-up.

A. Administer an antiemetic to prevent vomiting. B. Report the complaint of eye pain to the surgeon. C. Apply bilateral eye shields to reduce photosensitivity. D. Begin postoperative prophylactic antibiotics.

Correct Answer is B

Explanation

Choice A rationale

While nausea and vomiting can be side effects of eye surgery, they are not typically associated with acute pain deep within the eye following laser trabeculoplasty. Therefore, administering an antiemetic would not address the client’s primary complaint.

Choice B rationale

Acute pain deep within the eye following laser trabeculoplasty is not a typical postoperative symptom and could indicate a complication such as increased intraocular pressure or inflammation. Therefore, the nurse should report this complaint to the surgeon immediately for further evaluation.

Choice C rationale

While eye shields can help reduce photosensitivity after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.

Choice D rationale

While prophylactic antibiotics can help prevent infection after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.

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Following the administration of albuterol and the subsequent assessment, what actions should the nurse plan for the rest of the shift?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?

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

Explanation

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye.Which action should the nurse take?

Correct Answer is B

Explanation

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