After initializing a steroid nebulizer treatment for an asthmatic client in respiratory distress, which intervention is most important for the nurse to implement?

Elevate the head of the bed to 90 degrees.

Monitor pulse oximetry every 2 hours.

Determine exposure to asthmatic triggers.

Teach proper use of a rescue inhaler.

Answer and Explanation

The Correct Answer is A

Choice A reason: Elevating the head of the bed to 90 degrees is crucial for clients in respiratory distress. This position helps to maximize lung expansion, improve breathing, and alleviate respiratory effort. It provides immediate support to enhance oxygenation and ventilation.

Choice B reason: Monitoring pulse oximetry is important for assessing the client's oxygenation status but should be done continuously rather than every 2 hours in a client in respiratory distress.

Choice C reason: Determining exposure to asthmatic triggers is relevant for long-term management but not the immediate priority in an acute situation where the client is in respiratory distress.

Choice D reason: Teaching the proper use of a rescue inhaler is essential but should be done after stabilizing the client's condition. The immediate focus should be on interventions that provide rapid relief from respiratory distress.

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Correct Answer is B

Explanation

Choice A reason: Testing the urine for the presence of haematuria is important for diagnosing a urinary tract infection (UTI) or kidney stones, but it is not the most immediate intervention. Haematuria indicates blood in the urine, but assessing the client's vital signs is more urgent to determine if there is an acute issue that requires immediate attention.

Choice B reason: Measuring her temperature and heart rate is the most critical first step. These vital signs can provide immediate information about the client's overall condition and help identify potential systemic infection (fever) or hemodynamic instability (tachycardia). This information is essential for prioritizing further interventions and determining the urgency of the situation.

Choice C reason: Evaluating the urine for a strong Odor can help identify the presence of a UTI, but it is not as immediately critical as assessing the client's vital signs. Changes in urine Odor can support a diagnosis, but they do not provide the urgent information needed to assess the client's immediate health status.

Choice D reason: Palpating the right flank for tenderness is important for assessing kidney involvement, such as in cases of pyelonephritis (kidney infection). However, this physical examination should follow the assessment of vital signs to ensure the client is stable and not in immediate danger.

A. Keep the client NPO. B. Administer daily vitamin supplements. C. Provide protein-enriched shakes. D. Encourage small frequent meals.

Correct Answer is A

Explanation

Choice A reason: Keeping the client NPO (nothing by mouth) is essential to prevent further irritation of the gastrointestinal tract and to allow the postoperative stricture to heal. When the client is experiencing significant symptoms like nausea and vomiting, keeping them NPO can help manage these symptoms and prevent complications such as aspiration or worsening of the stricture.

Choice B reason: Administering daily vitamin supplements may be necessary for long-term nutritional management, especially after bariatric surgery. However, in the immediate setting of nausea, vomiting, and a postoperative stricture, this is not the priority intervention.

Choice C reason: Providing protein-enriched shakes may be beneficial for maintaining nutrition in the long term, but it is not appropriate when the client is experiencing nausea, vomiting, and anorexia. Oral intake should be limited until the symptoms subside and the stricture is addressed.

Choice D reason: Encouraging small frequent meals may be beneficial for managing long-term nutritional needs after bariatric surgery, but it is not appropriate during an acute episode of nausea, vomiting, and anorexia. The client should be kept NPO to prevent further complications and allow for proper healing.

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After initializing a steroid nebulizer treatment for an asthmatic client in respiratory distress, which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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