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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

Correct Answer is ["4"]

Explanation

Step 1 is to convert the child’s weight from pounds to kilograms.

44 pounds ÷ 2.2 = 20 kilograms.

Result at each step = 20 kilograms.

Step 2 is to calculate the total dosage of furosemide in milligrams.

2 mg × 20 kg = 40 mg.

Result at each step = 40 mg.

Step 3 is to determine the volume of medication to administer in milliliters.

40 mg ÷ 10 mg/mL = 4 mL.

Result at each step = 4 mL.

The nurse should administer 4 mL.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Correct Answer is D

Explanation

A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg intravenously every 12 hours. The medication is available at 10 mg/mL. How many mL should the nurse administer? (Enter numeric value only)

Correct Answer is ["4"]

Explanation

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