A 9-year-old patient is admitted to the pediatric unit with a diagnosis of status asthmaticus. Upon entering the hospital room, the nurse observes that the child is sitting and leaning forward on an overbed table. The patient's SpO2 is 93%. The nurse should take which action next?
Allow the patient to remain in the chosen position.
Place the patient in semi-Fowler's.
Administer 100% oxygen via a face mask.
Encourage consumption of cool, clear fluids.
The Correct Answer is B
Choice A rationale:
Allowing the patient to remain in the chosen position is inappropriate as the patient's position indicates distress. This choice should not be chosen.
Choice B rationale:
Placing the patient in semi-Fowler's position is the correct action. This position optimizes lung expansion and promotes easier breathing, which is crucial in managing status asthmaticus.
Choice C rationale:
Administering 100% oxygen via a face mask might be necessary eventually, but optimizing positioning takes precedence. Semi-Fowler's position should be established first.
Choice D rationale:
Encouraging consumption of cool, clear fluids is not the immediate priority in managing status asthmaticus. Respiratory support and positioning are more crucial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Meconium ileus is a concern in newborns with cystic fibrosis due to thick meconium, which can cause intestinal obstruction. At 16 years old, this complication is not relevant to the client's current condition.
Choice B rationale:
Blood-streaked sputum is a likely finding in a 16-year-old with cystic fibrosis and decreased pulmonary function. Cystic fibrosis leads to mucus accumulation and lung infections, which can cause blood vessels to rupture, resulting in blood-streaked sputum.
Choice C rationale:
Clear breath sounds bilaterally indicate healthy lung function, which is not expected in a client with cystic fibrosis and decreased PFT results. Breath sounds are likely to be diminished due to mucus accumulation.
Choice D rationale:
Dyspnea, or difficulty breathing, is a common symptom in clients with cystic fibrosis and decreased pulmonary function. However, the question asks about the expected findings that the nurse should assess, not a symptom that the client might report.
Correct Answer is B
Explanation
Choice A rationale:
Allowing the patient to stay in the chosen position might not be the best approach, as the child's preference might not align with therapeutic considerations for managing status asthmaticus.
Choice B rationale:
Semi-Fowler's position, with the head of the bed elevated, promotes improved lung expansion and easier breathing for patients with respiratory distress. Explaining the rationale behind this position to the child helps them understand its therapeutic benefits, encouraging compliance.
Choice C rationale:
Demonstrating various positions could confuse the child and delay appropriate intervention. A clear explanation of the preferred position is more effective in this critical situation.
Choice D rationale:
Removing pillows might be counterproductive, as elevating the head of the bed is beneficial for respiratory distress. This choice contradicts the therapeutic goal.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today