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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 B

Explanation

Rationale

A This statement is incorrect for diabetes management. People with diabetes should avoid soaking their feet in hot water, as it can lead to burns and skin damage, which is particularly risky due to potential nerve damage (neuropathy) and poor circulation common in diabetes.

B. This statement demonstrates good understanding. Alcohol can affect blood sugar levels and should be consumed in moderation by people with diabetes. Limiting intake to 1-2 drinks per day (following healthcare provider's advice) is generally recommended to minimize the impact on blood sugar levels and overall health.

C. Exercise is crucial for managing blood glucose levels in people with diabetes. Physical activity helps muscles use glucose for energy and can lower blood sugar levels. Understanding the importance of regular exercise is key for effective diabetes management.

D. While keeping wounds covered is generally good advice to prevent infection, using antibiotic ointment on every wound is not necessary unless specifically advised by a healthcare professional. Proper wound care, including cleaning with mild soap and water, keeping the wound clean and dry, and seeking medical attention for any signs of infection

A. Wear a face mask while performing wound care. B. Instruct the family to adhere to contact precautions. C. Report any increase in the white blood cell count. D. Change the surgical dressing readily when soiled.

Correct Answer is D

Explanation

Rationale

A. Wearing a face mask is a standard precaution to protect against airborne or droplet transmission of pathogens. However, MRSA is primarily transmitted through direct contact with infected wounds or contaminated surfaces rather than through the air.

B. Contact precautions are essential for preventing the spread of MRSA. These precautions include wearing gloves and gowns when in direct contact with the client or potentially contaminated surfaces. However, this is not of immediate concern.

C. Monitoring the white blood cell count (WBC) is crucial in assessing for signs of infection, including wound infections. An increase in WBC count can indicate systemic infection or local wound infection, which might be related to MRSA. Early detection and prompt reporting allow for timely intervention, such as initiating appropriate antibiotic therapy or further wound assessment.

D. This is because maintaining a clean environment around the wound is crucial to prevent infection

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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

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The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

Correct Answer is B

Explanation

Correct Answer is D

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.