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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?

A.

Monitor the oxygen saturation

B.

Prepare for deep tracheal suctioning

C.

Discuss potential asthma triggers with the client

D.

Obtain a sputum culture

E.

Consider positive pressure ventilation

F.

Allow the client to take a position of comfort

G.

Discuss aggressive respiratory treatment options

H.

Wean the supplemental oxygen .

Answer and Explanation

Correct Answer : A,C,F,H

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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Related Questions

Correct Answer is B

Explanation

Choice A rationale

Initiating bilateral intermittent sequential pneumatic compression devices is not the most appropriate immediate intervention for a patient showing signs of a possible stroke. These devices are typically used to prevent deep vein thrombosis in patients who are immobile, not for stroke management.

Choice B rationale

Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is the correct intervention. This position can help reduce intracranial pressure and facilitate venous drainage. In the case of a suspected stroke, it’s crucial to maintain proper cerebral blood flow.

Choice C rationale

Maintaining elevated positioning of the dependent joints on the affected side is not the immediate priority in stroke management. While it’s important to prevent contractures and maintain functional positioning, the immediate concern is to stabilize the patient’s condition.

Choice D rationale

Obtaining a focused history to determine recent bleeding and use of anticoagulants is important, but it’s not the first intervention. While this information will be necessary for the healthcare provider to determine the appropriate course of treatment, the immediate priority is to manage the patient’s acute symptoms.

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

Explanation

Based on the provided information, the following assessment findings require immediate follow-up by the nurse:

  • Difficulty breathing on a hike: This is a significant symptom of asthma exacerbation and needs immediate attention.
  • Symptoms did not resolve after taking albuterol: Albuterol is a quick-relief medication for asthma symptoms. If symptoms do not improve after its use, it indicates that the asthma exacerbation is severe.
  • Mild subcostal retractions: This is a sign of respiratory distress and indicates that the client is using accessory muscles to breathe.
  • Wheezes noted throughout the lung fields: Wheezing is a common sign of asthma and indicates airway obstruction.
  • The client is pale: Paleness can be a sign of decreased oxygenation.
  • Heart rate of 122 beats/minute: A high heart rate can be a sign of distress or could be due to the body’s attempt to compensate for decreased oxygenation.
  • Oxygen saturation of 91% on room air: Normal oxygen saturation is typically 95% or higher. A saturation of 91% indicates that the client is not getting enough oxygen.

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