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 C
Explanation
Choice A rationale:
Allowing a pacifier is appropriate and unrelated to the procedure.
Choice B rationale:
Feeding before the procedure helps prevent dehydration and maintains the infant's well-being.
Choice C rationale:
Bathing immediately after the procedure can introduce infection risk through the catheterization site. Waiting a day is advisable.
Choice D rationale:
Counting wet diapers helps monitor hydration post-procedure; it's a valid concern. In each case, the correct choices were determined by logical reasoning and adherence to medical guidelines. It's important for healthcare providers to educate patients and caregivers to ensure the best outcomes for patients' health and well-being.
Correct Answer is A
Explanation
Choice A rationale:
Monitoring the stool consistency is a crucial nursing action to assess the effectiveness of pancreatic enzyme replacement therapy. Patients with pancreatic insufficiency, such as those with cystic fibrosis, may have difficulty digesting fats properly. Improved stool consistency, specifically a reduction in greasy and foul-smelling stools, indicates that the pancreatic enzymes are aiding in fat digestion.
Choice B rationale:
Pupillary reflex response assessment is unrelated to pancreatic enzyme replacement therapy. It is more commonly performed to assess neurological status or the effects of medications affecting the autonomic nervous system.
Choice C rationale:
Listening to breath sounds is important for assessing respiratory status, but it does not directly reflect the effectiveness of pancreatic enzyme replacement therapy.
Choice D rationale:
Auscultating the apical pulse rate is a general assessment of cardiovascular function and does not provide information about the effectiveness of pancreatic enzyme replacement therapy.
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