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 A
Explanation
Choice B reason: Erythrocytes, hemoglobin, and hematocrit are laboratory results that are not as critical as serum potassium, calcium, and phosphorus in a client who has end-stage renal disease (ESRD.. Erythrocytes are red blood cells that carry oxygen from the lungs to the tissues. Hemoglobin is a protein in erythrocytes that binds oxygen. Hematocrit is the percentage of blood volume that is occupied by erythrocytes. ESRD can cause anemia (low erythrocyte, hemoglobin, and hematocrit levels) due to reduced production of erythropoietin, a hormone that stimulates erythrocyte formation, by the kidneys. Anemia can cause fatigue, pallor, or shortness of breath.
Choice C reason: Leukocytes, neutrophils, and thyroxine are laboratory results that are not as relevant as serum potassium, calcium, and phosphorus in a client who has end-stage renal disease (ESRD.. Leukocytes are white blood cells that fight infection and inflammation. Neutrophils are a type of leukocyte that respond to bacterial infection. Thyroxine is a hormone that regulates metabolism and growth. ESRD can cause leukopenia (low leukocyte levels) and neutropenia (low neutrophil levels) due to impaired immune function and increased susceptibility to infection. ESRD can also cause hypothyroidism (low thyroxine levels) due to reduced clearance of thyroid hormones by the kidneys. Hypothyroidism can cause weight gain, cold intolerance, or depression.
Choice D reason: Blood pressure, heart rate, and temperature are not laboratory results, but vital signs that should be monitored in a client who has end-stage renal disease (ESRD.. Blood pressure is the force of blood against the walls of the arteries. Heart rate is the number of times the heart beats per minute. Temperature is the measure of body heat. ESRD can cause hypertension (high blood pressurE. due to fluid overload and activation of the renin-angiotensin-aldosterone system, a hormonal pathway that regulates blood pressure and fluid balance. Hypertension can cause headache, chest pain, or stroke. ESRD can also cause tachycardia (high heart ratE. due to anemia, fluid overload, or electrolyte imbalance. Tachycardia can cause palpitations, dizziness, or heart failure. ESRD can also cause fever (high temperaturE. due to infection or inflammation. Fever can cause chills, sweating, or delirium.
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