A nurse is assessing several clients who have asthma. Which of the following clients should the nurse identify as requiring immediate intervention?
A client who is using accessory muscles to breathe
A client who has intermittent inspiratory and expiratory wheezes
A client who has an oxygen saturation of 94%
A client who has a daytime cough
The Correct Answer is A
A. A client who is using accessory muscles to breathe: The use of accessory muscles indicates severe respiratory distress and increased work of breathing. This is a sign that the client may be experiencing impending respiratory failure, requiring immediate intervention to prevent hypoxia and potential respiratory collapse. Prompt assessment and treatment, including oxygen therapy and bronchodilator administration, are critical.
B. A client who has intermittent inspiratory and expiratory wheezes: Wheezing is a common finding in asthma and may indicate mild to moderate bronchoconstriction. While it requires monitoring and treatment, it does not necessarily indicate immediate danger unless accompanied by other signs of severe distress.
C. A client who has an oxygen saturation of 94%: An oxygen saturation of 94% is slightly below normal but generally not an emergency in an otherwise stable client. It warrants monitoring and supplemental oxygen if it declines, but it does not require immediate intervention compared with signs of severe respiratory compromise.
D. A client who has a daytime cough: A daytime cough can be a symptom of asthma or poor control but is not an indicator of acute respiratory distress. This finding is important for long-term management but does not necessitate urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Inserting a tunneled central venous catheter: Insertion of a tunneled central venous catheter is a highly specialized invasive procedure that requires advanced training, sterile technique, and often physician or advanced practice provider privileges. This procedure is outside the legal scope of practice for a registered nurse.
B. Administering a platelet transfusion: Registered nurses are legally permitted to administer blood products, including platelets, after appropriate verification, assessment, and monitoring for transfusion reactions. This falls within the RN scope of practice and standard clinical protocols.
C. Irrigation of an external ear canal: External ear irrigation is considered a noninvasive procedure that RNs can perform safely, provided they follow proper technique and assess for contraindications such as tympanic membrane perforation. This is within the legal scope of practice for registered nurses.
D. Changing the inner cannula on a tracheostomy: Routine tracheostomy care, including changing the inner cannula, suctioning, and maintaining airway patency, is within the RN’s scope of practice. These tasks are considered essential nursing responsibilities for clients with artificial airways and do not require advanced privileges.
Correct Answer is ["10"]
Explanation
Calculation:
- Identify the prescribed dose and available concentration
Ordered Dose: 1,000 units/hr
Available: 25,000 units in 250 mL
- Calculate the concentration in units per mL
Concentration = 25,000 ÷ 250
Concentration = 100 units/mL
- Calculate the volume to administer per hour
Volume to administer = Ordered Dose ÷ Concentration
Volume to administer = 1,000 ÷ 100
= 10 mL/hr
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