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The nurse assesses the client after the dose of albuterol and documents the findings in the chart.

Exhibits

Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Allow the client to take a position of comfort

Discuss aggressive respiratory treatment options

Prepare for deep tracheal suctioning

Discuss with the client potential asthma triggers

Wean the supplemental oxygen

Obtain a sputum culture

Monitor the oxygen saturation

Consider positive pressure ventilation

Answer and Explanation

Correct Answer : A,D,G

A.   Allowing the client to find a comfortable position can help reduce anxiety and promote relaxation, which can be beneficial during an asthma exacerbation.
B.   While the patient is currently receiving treatment with albuterol and oxygen, discussing aggressive respiratory treatment options may not be necessary at this moment unless the patient's condition deteriorates and requires escalation of care.
C.   Deep tracheal suctioning is not indicated based on the current assessment findings unless there is a specific clinical indication such as excessive secretions or respiratory distress.
D.   Identifying and discussing potential triggers is important for asthma management. This helps the client understand what factors might exacerbate their asthma and how to avoid them in the future.
E.   Since the patient's oxygen saturation is still below target (91% on room air), weaning the supplemental oxygen is not appropriate at this time. The oxygen therapy should be continued as per the titration orders to maintain saturation above 94%.
F.   Obtaining a sputum culture is not typically indicated in acute asthma exacerbations unless there is suspicion of a secondary infection or if the patient develops persistent fever and productive cough.
G.   Continuously monitoring oxygen saturation is crucial to ensure it remains above 94%. This helps gauge the effectiveness of treatment and ensures the patient's respiratory status is stable.
H.   Positive pressure ventilation is a more advanced intervention and is not indicated based on the current assessment findings. It would only be considered if the patient's condition worsens despite maximal medical therapy.

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Correct Answer is ["A","B","C"]

Explanation

Blood pressure 90/62 mm Hg

A blood pressure of 90/62 mm Hg indicates hypotension, which could be indicative of hypovolemia (low blood volume) due to postpartum hemorrhage. Hypotension needs immediate evaluation and intervention to prevent further complications.

Oxygen saturation of 89%

An oxygen saturation of 89% on room air is below the normal range (typically 95-100%). This suggests the client is not adequately oxygenating, which could be due to various reasons such as respiratory compromise or inadequate ventilation. Immediate follow-up is necessary to determine the cause and initiate appropriate interventions.

Fundus rotated to the right

The displacement of the fundus could be due to the presence of a distended bladder pushing the uterus to one side which may increase uterine atony.

Correct Answer is ["18"]

Explanation

(Desired Dose * Volume of IV Bag) / (Concentration of Drug in IV Bag * Time) = Infusion Rate.

For the given prescription, the calculation would be: (900 units/hr * 500 mL) / (25,000 units) = 18 mL/hr.

Therefore, the nurse should program the infusion pump to deliver 18 mL/hr.

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The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A client receives a prescription for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["18"]

Explanation

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The nurse assesses the client after the dose of albuterol and documents the findings in the chart.

Exhibits

Which action(s) should the nurse plan for the rest of the shift? Select all that apply.