Patient Data
After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen.
Which action(s) should the nurse take next? Select all that apply.
Administer additional nebulizer treatment as ordered.
Take and monitor vital signs.
Apply a nonrebreather oxygen mask.
Increase oxygen flow.
Raise the head of the bed.
Provide client incentive spirometer and instruct on use.
Correct Answer : A,B,D,E
Inhaled short acting beta agonists can should be administered up to 3 times until there the obstruction in managed. In the event that the nebulization fails to relieve the respiratory distress, other treatment options such as magnesium sulphate can be used.
Oxygen flow should also be titrated appropriately to achieve the targeted SPO2 levels. However, changing the modality of oxygen delivery is not necessary at this part.
Continuous vital signs monitoring allows for timely interventions at all times to prevent respiratory failure. Although not a primary measure, raising the head of the bed can increase comfort reducing the work of breathing.
While incentive spirometry may have a role in the management of asthma in certain situations, such as during the recovery phase after an acute exacerbation or in individuals with chronic asthma who have reduced lung function, it is not typically used as a primary intervention during the acute phase of an asthma attack.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Raynaud's syndrome is characterized by vasospasm of the small arteries, often triggered by exposure to cold temperatures or stress. Keeping the workspace warm can help prevent vasospasm and reduce the risk of Raynaud's attacks while the client is working. Using a space heater or adjusting the office temperature can help maintain a comfortable environment for the client.
B. While vitamin D supplementation may have various health benefits, it is not specifically indicated for managing Raynaud's syndrome.
C. Elevating the hands during work breaks may help reduce swelling or discomfort associated with certain conditions, but it is not a specific recommendation for managing Raynaud's syndrome. Elevating the hands may not address the underlying issue of reduced blood flow to the fingers that occurs during Raynaud's attacks.
D. Limiting wrist flexion may help reduce strain on the wrists and hands but would not directly address the symptoms of Raynaud's syndrome related to blood flow. While ergonomic keyboards can be beneficial for preventing repetitive strain injuries and improving comfort during typing, they are not specifically indicated for managing Raynaud's syndrome.
Correct Answer is C
Explanation
C. Herpes zoster is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox (varicella). Asking whether everyone at home has already had varicella helps assess the risk of exposure to susceptible individuals who could potentially develop chickenpox upon exposure to the herpes zoster rash.
A. Sharing combs and brushes may increase the risk of transmitting head lice, fungal infections, or bacterial infections, but it is not directly relevant to the assessment of herpes zoster.
B. Dry patches on the feet and hands may be indicative of various dermatological conditions such as eczema or psoriasis, but they are not specific to herpes zoster. Herpes zoster typically presents as a painful rash with clusters of fluid-filled blisters along a specific dermatome
D. Asking about the effectiveness of antifungal creams is relevant if the client is being treated for a fungal infection, but it does not provide information specific to herpes zoster.
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