A nurse is caring for a client in the emergency department. Which action should the nurse take based on the client’s medication administration record at 1130?
Administer Albuterol nebulizer 2.5 mg stat.
Administer Methylprednisolone 50 mg IV stat.
Reassess the client’s vital signs before administering medications.
Notify the provider if the client has worsening symptoms after administration.
The Correct Answer is C
Choice A rationale
Administering Albuterol nebulizer 2.5 mg stat is appropriate for acute bronchospasm. Albuterol is a beta-agonist that relaxes airway smooth muscles, improving oxygenation. It is only administered when clinically indicated.
Choice B rationale
Methylprednisolone 50 mg IV is used for severe inflammation. It suppresses immune responses and reduces cytokine activity, but it does not directly address acute symptoms needing immediate intervention.
Choice C rationale
Reassessing vital signs ensures the patient’s stability before administering medications. This is vital in emergencies to evaluate therapy needs and prevent further clinical deterioration.
Choice D rationale
Notifying the provider about worsening symptoms after administration ensures timely interventions. However, preemptive measures, like reassessing stability, take priority before escalation.
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Correct Answer is D
Explanation
Choice A rationale
Suggesting that the situation will improve over time lacks therapeutic value and may dismiss the client’s current emotions, failing to provide active emotional support or promote coping mechanisms.
Choice B rationale
Acknowledging the difficulty of the situation validates the client’s feelings but does not encourage engagement in active coping strategies or provide constructive emotional assistance.
Choice C rationale
Recommending talking to a chaplain assumes the client’s preference for spiritual support without addressing their immediate concerns or fostering problem-solving and emotional expression.
Choice D rationale
Encouraging the client to reflect on past coping mechanisms promotes problem-solving, emotional expression, and the utilization of effective strategies previously used, fostering therapeutic engagement and resilience.
Correct Answer is B
Explanation
Choice A rationale
Exercising close to bedtime increases adrenaline and body temperature, which interfere with sleep initiation. Studies recommend ceasing vigorous activity at least 3-4 hours before bedtime to optimize sleep quality.
Choice B rationale
Reducing fluid intake before bed minimizes nocturia, a common sleep disturbance. This aligns with promoting uninterrupted sleep and improving overall sleep hygiene and quality for individuals with insomnia.
Choice C rationale
Taking daytime naps, especially longer than 30 minutes, disrupts circadian rhythms and sleep drive, contributing to difficulty initiating and maintaining sleep during regular hours.
Choice D rationale
Eating a large meal before bedtime delays gastric emptying and may cause discomfort or reflux, both of which interfere with falling asleep. Light snacks are recommended if needed, but not heavy meals.
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