A client is admitted to the emergency room with an asthma attack. To decrease the client's dyspnea and anxiety, which of the following interventions will the nurse perform?

Let the client rest alone in a quiet, calm environment.

Reassure the client that the doctor will arrive soon.

Place the client on a cardiac monitor and observe from the nurse's station.

Stay with the client and encourage pursed-lip breathing.

Answer and Explanation

The Correct Answer is D

A. Letting the client rest alone is not an appropriate intervention for an asthma attack. The client needs reassurance and support during an asthma exacerbation, and isolation can increase anxiety and worsen symptoms.

B. Reassuring the client that the doctor will arrive soon may provide some comfort, but it does not directly address the acute symptoms of dyspnea and anxiety. Immediate interventions to manage the asthma attack should be prioritized.

C. Placing the client on a cardiac monitor and observing from the nurse's station may be appropriate for monitoring heart rate and rhythm, but it does not address the primary concern of managing the asthma attack or anxiety. The nurse should be present to provide direct support and interventions.

D. Staying with the client and encouraging pursed-lip breathing is an effective intervention for managing anxiety and dyspnea during an asthma attack. Pursed-lip breathing helps the client slow their breathing, improve ventilation, and reduce anxiety, which can alleviate dyspnea.

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Correct Answer is D

Explanation

A. Securing the oxygen tubing to the bed sheet near the client's head is not an appropriate action because it may lead to accidental disconnection or kinking of the tubing, which could impair oxygen delivery. Tubing should be secured in a way that minimizes movement and risk of interference.

B. Removing the nasal cannula while the client eats is not recommended, as it interrupts oxygen therapy, potentially causing hypoxia. The client can usually eat with the nasal cannula in place unless instructed otherwise.

C. Applying petroleum jelly to the nares is contraindicated because petroleum jelly is flammable and poses a safety risk in the presence of oxygen. Water-based lubricants should be used instead to soothe mucous membranes.

D. Attaching a humidifier bottle to the base of the flow meter is the correct action for oxygen therapy at 4L/min. Humidification helps prevent dryness and irritation of the mucous membranes caused by prolonged oxygen therapy.

A. Notify the client's family to come visit client B. Instruct the client return to their room C. Ask the unlicensed assistive personnel (UAP) to push fluids D. Assess the client's lung fields and temperature

Correct Answer is D

Explanation

A. Notifying the client's family may be appropriate after assessing the client and identifying the cause of the confusion. However, it is not the first action, as the priority is to determine if the confusion is due to a medical condition requiring immediate attention.

B. Instructing the client to return to their room addresses the wandering behavior but does not address the underlying cause of the new onset confusion. Without further assessment, this action may delay necessary interventions.

C. Asking the UAP to push fluids assumes that dehydration is the cause of the confusion without evidence. While encouraging hydration may be beneficial later, it is essential first to assess for other potential causes, such as infection or hypoxia.

D. Assessing the client's lung fields and temperature is the first priority because new onset confusion in an older adult is often a symptom of an underlying medical issue, such as infection (e.g., pneumonia or urinary tract infection) or hypoxia. Early assessment helps identify the cause and guide appropriate interventions.

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A client is admitted to the emergency room with an asthma attack. To decrease the client's dyspnea and anxiety, which of the following interventions will the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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