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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 C

Explanation

Choice A rationale

Monitoring an IV infusion rate on an established schedule requires assessment skills and clinical judgement to identify and respond to potential complications. This task should be performed by a registered nurse.

Choice B rationale

Titration of oxygen to prescribed parameters is a complex task that requires advanced assessment skills and a deep understanding of the patient’s condition and response to treatment. This task should not be delegated to unlicensed assistive personnel (UAP).

Choice C rationale

Inserting a urinary catheter for an uncomplicated patient is a task that can be safely delegated to UAP who have been trained and demonstrated competence in this skill. It is a routine procedure and does not require advanced assessment or decision-making skills.

Choice D rationale

Procuring platelet products from the blood bank is a task that involves handling and transporting biological materials, which requires specific knowledge and skills. This task should not be delegated to UAP.

A. Nitroglycerin. B. Aspirin. C. Morphine. D. Heparin.

Correct Answer is A

Explanation

Choice A rationale

Nitroglycerin is a medication that is commonly used to treat chest pain or angina. However, it is contraindicated in patients who have taken sildenafil (Viagra) within the last 24 hours due to the risk of severe hypotension, or low blood pressure. Sildenafil is a type of medication known as a phosphodiesterase-5 (PDE5) inhibitor, which works by relaxing the muscles in the walls of blood vessels. Nitroglycerin also works by relaxing blood vessels, so the combination of these two medications can cause a dangerous drop in blood pressure.

Choice B rationale

Aspirin is not typically withheld in patients experiencing chest pain. It is often given to patients who are suspected of having a heart attack because it works by preventing blood clots from forming and blocking the blood vessels of the heart.

Choice C rationale

Morphine is often administered to patients experiencing severe chest pain to help relieve the pain and reduce the workload of the heart. It is not typically withheld unless the patient has a known allergy or other contraindication.

Choice D rationale

Heparin is a blood thinner that is often administered to patients who are suspected of having a heart attack to prevent further blood clots from forming. It is not typically withheld unless the patient has a known allergy, other contraindication, or is at high risk of bleeding.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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