A college health nurse interprets the peak expiratory flow rate for 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's asthma is not well controlled.
The nurse should obtain a second expiratory flow rate.
The student needs to go to the hospital.
The student should use his quick-relief inhaler.
The student's peak flow is 50% to 80% of his best peak flow.
Correct Answer : A,D,E
A. The student's asthma is not well controlled: Being in the yellow zone indicates that the student's asthma is not well controlled and that their peak expiratory flow rate (PEFR) is lower than usual. This is a crucial point for the nurse to recognize, as it suggests that the student may need to adjust their management plan to prevent an exacerbation.
B. The nurse should obtain a second expiratory flow rate: While it can be helpful to reassess peak flow rates, it is not always necessary unless there is a concern about the accuracy of the initial measurement. The initial yellow zone result provides sufficient information for the nurse to take appropriate action regarding the student's asthma management.
C. The student needs to go to the hospital: Being in the yellow zone does not automatically require hospitalization. The yellow zone typically indicates that the student is experiencing some worsening of asthma symptoms but can often be managed at home with appropriate interventions. Hospitalization is usually reserved for the red zone, where severe symptoms or a significant decrease in peak flow occurs.
D. The student should use his quick-relief inhaler: This is an appropriate action for a student in the yellow zone. The yellow zone often indicates the need for the use of a quick-relief inhaler to alleviate symptoms and improve airflow. The nurse should advise the student to use their inhaler as per their asthma action plan.
E. The student's peak flow is 50% to 80% of his best peak flow: This statement accurately describes the yellow zone, where the peak flow is between 50% and 80% of the student's personal best. This information is essential for determining the appropriate response to the current asthma status and guides the nurse's actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Standard: While a standard resume format includes basic information about education and experience, it may not effectively address the nurse's multiple moves and varied positions, potentially raising concerns about stability and commitment.
B. Functional: This resume type is most appropriate for the nurse in this situation as it focuses on skills and experiences rather than a chronological work history. This format allows the nurse to highlight relevant skills gained in different positions without emphasizing the frequent changes in employment, which could be beneficial in presenting a cohesive professional narrative.
C. Sequence: This term is less commonly used in resume types and may not provide clarity in presenting qualifications or experiences.
D. Chronological: While this format lists experiences in reverse chronological order, it may draw attention to the frequent changes in positions and locations, which could raise red flags for potential employers regarding the nurse's commitment and stability in a job.
Correct Answer is ["B","C","D"]
Explanation
A. Hypotension: While hypotension can occur in clients with acute respiratory failure (ARF), it is not a primary manifestation of the condition. Hypotension may arise due to other factors, such as sepsis or significant fluid loss, but is not universally present in ARF. Therefore, it is less likely to be a key finding in this context.
B. Severe dyspnea: This is a hallmark manifestation of ARF. Clients typically experience significant difficulty in breathing due to inadequate oxygenation or ventilation, leading to an urgent need for medical intervention. Monitoring for severe dyspnea is critical as it directly indicates the severity of respiratory distress.
C. Headache: Headaches can be a manifestation of acute respiratory failure, particularly due to hypoxia or hypercapnia (elevated carbon dioxide levels) affecting cerebral circulation. This symptom may arise as the body struggles to compensate for decreased oxygen levels, making it important to monitor in clients with ARF.
D. Decreased level of consciousness: This is a significant concern in ARF and can indicate worsening hypoxia or hypercapnia. Alterations in consciousness may range from confusion to unresponsiveness and require immediate evaluation and intervention, making it a critical manifestation to monitor.
E. Nausea: Although some clients may experience nausea as a secondary symptom due to anxiety or as a response to hypoxia, it is not a primary or definitive manifestation of acute respiratory failure. Therefore, while it may occur in some cases, it is not one of the key findings to consistently monitor in clients with ARF.
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