Sara is receiving a nebulized albuterol treatment for her asthma exacerbation. Which of the following should be the nurse’s first priority after administering the treatment?

Auscultate Sara’s lung sounds.

Measure Sara’s temperature.

Encourage Sara to ambulate

Document the treatment in her medical record.

Answer and Explanation

The Correct Answer is A

Choice A reason: Auscultating lung sounds post-albuterol assesses treatment efficacy in asthma exacerbation. Reduced wheezing or improved air entry indicates bronchodilation, guiding further care, making it the priority to evaluate respiratory response immediately.

Choice B reason: Measuring temperature monitors infection, a possible asthma trigger, but it’s not the priority post-treatment. Albuterol targets acute bronchospasm, so assessing respiratory effect trumps systemic checks like fever in this moment.

Choice C reason: Encouraging ambulation is premature post-albuterol; patients need rest during exacerbation. It risks worsening dyspnea before confirming treatment success, making it less urgent than evaluating lung response to the bronchodilator.

Choice D reason: Documentation is essential but secondary to patient assessment post-treatment. Auscultating lung sounds first ensures albuterol’s effect is evaluated, as clinical response guides care before recording in the record.

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Correct Answer is A

Explanation

Choice A reason: Low-impact exercise, like walking, enhances collateral circulation in PAD, increasing blood flow to ischemic muscles. It reduces claudication by stimulating angiogenesis and improving endothelial function, a cornerstone of evidence-based management to alleviate symptoms effectively.

Choice B reason: Limiting fluid intake addresses edema, not a primary PAD issue, which involves arterial insufficiency, not venous stasis. This strategy lacks scientific support for claudication relief, as hydration status doesn’t directly influence arterial perfusion.

Choice C reason: Tight shoes restrict circulation, worsening PAD by compressing arteries and exacerbating ischemia. Proper footwear is essential, but constriction contradicts vascular physiology, potentially increasing pain and tissue damage rather than improving blood flow.

Choice D reason: Bed rest reduces activity, promoting stasis and deconditioning in PAD, worsening claudication. Immobility decreases muscle pump action and collateral flow, conflicting with evidence that exercise improves symptoms, making this detrimental to recovery.

A. Turn and reposition the patient. B. Assist the patient with incentive spirometry. C. Clamp the chest tube in two places. D. Administer prescribed morphine.

Correct Answer is D

Explanation

Choice A reason: Repositioning may ease discomfort but won’t address severe pain (7/10) or reduced breath sounds post-thoracotomy. It risks dislodging tubes and doesn’t improve atelectasis or bleeding, lacking urgency for this acute scenario.

Choice B reason: Incentive spirometry prevents atelectasis, but pain limits participation. Decreased breath sounds suggest collapse, yet without pain control, this intervention is ineffective, delaying relief and lung expansion needed post-surgery.

Choice C reason: Clamping a chest tube risks tension pneumothorax by trapping air or blood, worsening breathing. With 100 mL drainage, it’s functioning; clamping is contraindicated unless ordered, making it dangerous here.

Choice D reason: Morphine reduces severe pain (7/10), enabling deeper breathing to reverse atelectasis. It addresses the primary barrier to recovery post-thoracotomy, improving ventilation and comfort, aligning with acute pain management protocols.

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Sara is receiving a nebulized albuterol treatment for her asthma exacerbation. Which of the following should be the nurse’s first priority after administering the treatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 65-year-old patient with a history of Peripheral Artery Disease (PAD) presents to the clinic with complaints of intermittent claudication in the right leg. Which of the following management strategies should the nurse prioritize to improve the patient’s condition?

Correct Answer is A

Explanation

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage. Which action would the nurse take?

Correct Answer is D

Explanation

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