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: Assessing pupillary response to light hourly is not an intervention that the nurse should implement while administering dopamine, as this is not related to the effects or side effects of dopamine. This is a distractor choice.
Choice B: Initiating seizure precautions is not an intervention that the nurse should implement while administering dopamine, as this is not a common or expected complication of dopamine. This is another distractor choice.
Choice C: Monitoring serum potassium frequently is not an intervention that the nurse should implement while administering dopamine, as this is not affected by dopamine or hypotension. This is another distractor choice.
Choice D: Measuring urinary output every hour is an intervention that the nurse should implement while administering dopamine, as this can indicate the effectiveness of dopamine in improving renal perfusion and blood pressure. Therefore, this is the correct choice.
Correct Answer is ["30"]
Explanation
First, we need to find the concentration of insulin in the IV solution, which is the ratio of insulin units to saline volume. To do this, we use the given information that the IV solution contains 100 units in 250 ml. So, we divide 100 by 250 and get 0.4 units/ml.
Next, we need to calculate the infusion rate in ml/hour for the ordered dose of 12 units/hour. To do this, we use the ratio of insulin units to saline volume, which is 0.4 units/ml. So, we set up a proportion as follows:
0.4/1=12/x
To solve for x, we cross-multiply and get 0.4 x = 12. Then, we divide both sides by 0.4 and get x = 30. So, the infusion rate is 30 ml/hour.
Therefore, the nurse should program the infusion pump to deliver 30 ml/hour..
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