A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all that apply.)
The student needs to go to the hospital.
The nurse should obtain a second expiratory flow rate.
The student's peak flow is 50% to 80% of his best peak flow.
The student should use his quick-relief inhaler.
The student's asthma is not well controlled,
Correct Answer : B,C,D,E
Asthma action plans often use a color-coded system to guide management based on peak expiratory flow rate (PEFR) measurements. The zones are typically green (80-100% of personal best), yellow (50-79% of personal best), and red (less than 50% of personal best).
A. The student needs to go to the hospital.
This is not necessarily required when the student is in the yellow zone. The yellow zone indicates caution and the need for intervention, but it does not immediately require hospitalization unless symptoms worsen or do not improve after using the quick-relief inhaler.
B. The nurse should obtain a second expiratory flow rate.
Confirming the peak flow measurement with a second reading ensures accuracy and helps to make informed decisions about the student's asthma management.
C. The student should use his quick-relief inhaler.
In the yellow zone, indicating moderate impairment, the use of a quick-relief (rescue) inhaler is often recommended to relieve symptoms and prevent progression to the red zone.
D. The student's peak flow is 50% to 80% of his best peak flow.
This is the correct range for the yellow zone, indicating moderate impairment. Action is needed to prevent worsening.
E. The student's asthma is not well controlled.
Being in the yellow zone indicates that the asthma is not well controlled and may require adjustments in the long-term management plan, including possible changes to daily controller medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "These tests help determine the degree of damage to the heart tissues." - This is the correct statement. Cardiac enzyme studies, such as creatine kinase (CK), CK-MB, troponin I, and troponin T, are used to assess the extent of myocardial damage during an acute myocardial infarction (MI). Elevated levels of these enzymes indicate myocardial injury and help healthcare providers determine the severity of the heart tissue damage.
B. "Cardiac enzymes will identify the location of the MI." - While cardiac enzymes can confirm the presence of an MI, they do not specifically identify the location of the infarction. Other diagnostic tools, such as electrocardiogram (ECG) and imaging studies, may help determine the location of the MI.
C. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." - Cardiac enzymes are not used to diagnose pulmonary congestion. Other diagnostic methods, such as chest X-rays and physical examination, are more appropriate for assessing pulmonary congestion.
D. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." - Cardiac enzyme studies do not provide information about the overall heart structure or the mobility of heart valves. Imaging studies, such as echocardiography, are used for this purpose.
Correct Answer is B
Explanation
A. Maintaining a semi-Fowler's position as often as possible: While maintaining an elevated position can assist with breathing, it may not directly address the issue of tenacious bronchial secretions. Adequate hydration and other measures are often more effective.
B. Encouraging the client to drink 2 to 3 L of water daily: This is the correct answer. Adequate hydration helps to thin mucus, making it easier to clear from the airways. Drinking 2 to 3 liters of water daily is a helpful strategy to promote hydration and reduce the viscosity of bronchial secretions.
C. Helping the client select a low-salt diet: While a low-salt diet may have cardiovascular benefits, it is not a primary intervention for addressing tenacious bronchial secretions. Hydration and airway clearance techniques are more directly relevant.
D. Administering oxygen via nasal cannula at 2 L/min: While oxygen therapy may be necessary in COPD, it is not the primary intervention for managing tenacious bronchial secretions. Hydration and other measures aimed at thinning mucus are more appropriate.
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