While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed lip breathing. Which intervention should the nurse implement?

Increase oxygen to 6 liters/minute.

Call for an Ambu resuscitation bag.

Instruct the client to lie back in bed.

Administer a nebulizer treatment.

Answer and Explanation

The Correct Answer is D

Choice A reason: Increasing oxygen to 6 liters/minute is not an intervention that the nurse should implement, as this can worsen the bronchospasm and hypoxia by reducing the hypoxic drive and causing carbon dioxide retention. This is a contraindicated choice.

Choice B reason: Calling for an Ambu resuscitation bag is not an intervention that the nurse should implement, as this is not indicated for a client who is conscious and breathing spontaneously. This is an overreaction choice.

Choice C reason: Instructing the client to lie back in bed is not an intervention that the nurse should implement, as this can increase respiratory distress and compromise airway clearance by reducing lung expansion and increasing abdominal pressure. This is another contraindicated choice.

Choice D reason: Administering a nebulizer treatment is an intervention that the nurse should implement, as this can deliver bronchodilators and anti-inflammatory agents directly to the airways and improve ventilation and oxygenation for this client. Therefore, this is the correct choice.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

Choice A reason: Obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a nursing action that the nurse can assign to the PN, as this is a basic skill that does not require complex judgment or intervention by the registered nurse. Therefore, this is a correct choice.

Choice B reason: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that the nurse should assign to the PN, as this is an advanced skill that requires close monitoring and evaluation by the registered nurse. This is an incorrect choice.

Choice C reason: Initiating patient controlled analgesia (PCA) pumps for two clients immediately postoperatively is not a nursing action that the nurse should assign to the PN, as this involves administering controlled substances and assessing pain levels, which are beyond the scope of practice of the PN. This is another incorrect choice.

Choice D reason: Performing daily surgical dressing change for a client who had an abdominal hysterectomy is a nursing action that the nurse can assign to the PN, as this is a routine task that can be done under the supervision and direction of the registered nurse. Therefore, this is another correct choice.

Choice E reason: Administering a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM) is a nursing action that the nurse can assign to the PN, as this is an established protocol that can be followed by the PN with appropriate documentation and reporting. Therefore, this is another correct choice.

A. Center attention on positive upbeat music. B. Find outlets for more social interaction. C. Practice using muscle relaxation techniques. D. Think about reasons the episodes occur.

Correct Answer is C

Explanation

Choice A reason: Centering attention on positive upbeat music is not a specific instruction for the nurse to include, as this is a general coping strategy that may or may not be helpful for this client. This is a distractor choice.

Choice B reason: Finding outlets for more social interaction is not a relevant instruction for the nurse to include, as this may not address the underlying causes of anxiety or stress for this client. This is another distractor choice.

Choice C reason: Practicing using muscle relaxation techniques is an appropriate instruction for the nurse to include, as this can help reduce physical tension and promote calmness and relaxation for this client. Therefore, this is the correct choice.

Choice D reason: Thinking about reasons the episodes occur is not a helpful instruction for the nurse to include, as this can increase rumination and anxiety for this client. This is another distractor choice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)

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

Explanation

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Correct Answer is C

Explanation

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donninggloves and a gown to assist the client. Which action should the nurse take?

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns on both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?

A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?

Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

A client with obsessive-compulsive disorder (OCD) is repeatedly washing the top of the same table. Which intervention should the nurse implement?

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding this client?