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 bedside 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.
The Correct Answer is D
Choice A: Increasing oxygen to 6 liters/minute is not an intervention that the nurse should implement, as this can worsen bronchospasm and hypoxia by reducing the hypoxic drive and causing carbon dioxide retention. This is a contraindicated choice.
Choice B: 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: 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: 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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Which medication works best for you? This is not the most important question, as it does not address the current status or risk of the client. The medication history is a part of the assessment, but it does not help identify the content or impact of the hallucinations.
Choice B: When do you hear voices? This is not the most important question, as it does not address the current status or risk of the client. The frequency and timing of the hallucinations are a part of the assessment, but they do not help identify the content or impact of the hallucinations.
Choice C: How do you cope with the voices? This is not the most important question, as it does not address the current status or risk of the client. The coping strategies are a part of the assessment, but they do not help identify the content or impact of the hallucinations.
Choice D: What are the voices saying? This is the most important question, as it addresses the current status and risk of the client. The content and impact of the hallucinations are a part of the assessment, as they can help identify if the client is experiencing command hallucinations, which may instruct them to harm themselves or others.
Correct Answer is D
Explanation
Choice A: Administering a half dose now is not a safe instruction for the nurse to provide, as this can result in overdosing or underdosing the infant, depending on how much of the medicine was absorbed or expelled. This is a contraindicated choice.
Choice B: Giving another dose is not a prudent instruction for the nurse to provide, as this can cause digoxin toxicity, which can be life-threatening for the infant. This is another contraindicated choice.
Choice C: Mixing the next dose with food is not a relevant instruction for the nurse to provide, as this does not address the current situation and can affect the absorption and effectiveness of digoxin. This is a distractor choice.
Choice D: Withholding this dose is a sensible instruction for the nurse to provide, as this can prevent adverse effects and allow the infant's serum digoxin level to be checked before giving another dose. Therefore, this is the correct choice.
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