A nurse instructs a 60-year-old client diagnosed with asthma about using a peak expiratory flow meter. Which immediate action should the nurse recommend to the client that obtains a reading of 82% on their peak flow meter?

Go to the emergency department

Continue to use salmeterol and fluticasone as prescribed

Administer an additional rescue dose of Albuterol

Call the physician

Answer and Explanation

The Correct Answer is C

A) Go to the emergency department:
An immediate trip to the emergency department is generally not required for a peak expiratory flow rate (PEFR) of 82%. The PEFR of 82% indicates that the client’s airflow is reduced, but it is not necessarily an emergency. PEFR readings are typically classified into zones: green (80-100% of personal best), yellow (50-79% of personal best), and red (below 50% of personal best). A reading of 82% is in the yellow zone, which suggests that the client is experiencing some degree of airway obstruction or worsening asthma symptoms

B) Continue to use salmeterol and fluticasone as prescribed:
While salmeterol (a long-acting beta agonist) and fluticasone (a corticosteroid) are important for long-term asthma control, continuing their use without additional intervention is not the most appropriate action when the PEFR is 82%. A PEFR of 82% indicates that the client’s asthma is not well controlled at the moment, and the nurse should recommend additional short-acting relief to help open the airways (e.g., a rescue inhaler like albuterol.

C) Administer an additional rescue dose of Albuterol:
The correct immediate action is to administer a rescue dose of albuterol. Albuterol is a short-acting beta-agonist that helps open the airways quickly during an asthma exacerbation. A PEFR of 82% falls in the yellow zone, suggesting some obstruction but not an emergency situation. In this case, administering an additional rescue dose of albuterol can help improve airflow and bring the PEFR closer to normal.

D) Call the physician:
While it may be necessary to call the physician if the client’s asthma symptoms do not improve after using a rescue inhaler or if there is a significant decline in symptoms, the first immediate action should be to use a rescue medication like albuterol. Calling the physician may be appropriate after assessing the response to the rescue medication, but it is not the first step in managing a PEFR of 82%.

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Correct Answer is D

Explanation

A) Cyanosis:
Cyanosis, which is a bluish discoloration of the skin and mucous membranes, typically occurs with severe hypoxia or oxygen deprivation, usually when oxygen saturation levels drop below 85%. Cyanosis is a late sign of hypoxia, not an early sign. In the early stages of hypoxia, the body attempts to compensate, and cyanosis does not typically appear until oxygen levels are significantly low.

B) Hypotension:
While hypotension can be a consequence of severe or prolonged hypoxia, it is generally a late sign. In the early stages of hypoxia, the body compensates through mechanisms such as tachycardia and vasoconstriction, so hypotension would not be expected at this stage. Hypotension in a hypoxic patient usually signals progression to severe respiratory or circulatory failure.

C) Bradycardia:
Bradycardia (slow heart rate) is not typically associated with early hypoxia. Instead, the body tries to compensate for reduced oxygen levels by increasing heart rate (tachycardia) in the early stages. Bradycardia can occur in more severe stages of hypoxia, particularly if the body begins to struggle with compensating or if the patient progresses to a more critical state. However, it is not an early sign of hypoxia.

D) Tachycardia:
Tachycardia (an elevated heart rate) is an early compensatory mechanism that the body employs when oxygen levels are insufficient. The heart increases its rate to pump more blood (and thus oxygen) to vital organs and tissues. Tachycardia is one of the earliest signs of hypoxia and occurs as the body attempts to compensate for the decreased oxygen levels in the bloodstream.

A. Prepare the client for mechanical ventilation. B. Instruct the client to perform the pursed lip breathing. C. Prepare to administer IVIG. D. Administration of an immunosuppressant.

Correct Answer is A

Explanation

A) Prepare the client for mechanical ventilation:
A myasthenic crisis is a medical emergency characterized by severe weakness of the respiratory muscles, leading to respiratory failure. This can result from insufficient levels of acetylcholine due to insufficient medication (e.g., pyridostigmine) or from an infection. In such cases, airway support is the priority. The nurse should first prepare the client for potential mechanical ventilation to ensure they can breathe properly and to prevent respiratory arrest.

B) Instruct the client to perform pursed-lip breathing:
While pursed-lip breathing is a useful technique to help with shortness of breath and improve ventilation in certain respiratory conditions (like COPD), it is not the first action in managing a myasthenic crisis. The immediate priority is to ensure the client can breathe and maintain oxygenation, which may require mechanical ventilation if the respiratory muscles are too weak to support breathing effectively.

C) Prepare to administer IVIG:
IV immunoglobulin (IVIG) can be used in the treatment of myasthenic crisis by suppressing the immune response and increasing acetylcholine receptor activity. However, IVIG is not typically the first intervention. Respiratory support and stabilization should take precedence, especially if there is significant respiratory distress.

D) Administration of an immunosuppressant:
Immunosuppressive therapy, such as corticosteroids or azathioprine, may be used to manage myasthenia gravis over the long term, but it is not an acute intervention for a myasthenic crisis. The immediate priority in a crisis situation is to manage respiratory distress and ensure airway protection.

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A nurse instructs a 60-year-old client diagnosed with asthma about using a peak expiratory flow meter. Which immediate action should the nurse recommend to the client that obtains a reading of 82% on their peak flow meter?

Nursing Test Bank

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Explanation

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Correct Answer is A

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