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 A

Explanation

Choice A reason: Taking a walk with the client is an effective intervention for addressing agitation and restlessness in a client with Alzheimer's disease. Physical activity can help reduce anxiety and agitation, and walking provides a safe and structured way for the client to expend energy while being closely supervised.

Choice B reason: Sitting the client in a recliner may provide temporary comfort, but it does not address the underlying agitation and restlessness. The client may still attempt to leave the room and become more frustrated if their movement is restricted.

Choice C reason: Administering a sleeping medication can have sedative effects, but it should not be the first-line intervention for agitation and restlessness in clients with Alzheimer's disease. Non-pharmacological approaches, such as walking, should be tried first. Sedatives can also increase the risk of falls and other complications.

Choice D reason: Moving the client to a locked unit may be necessary for safety in some cases, but it should not be the initial intervention for agitation and restlessness. The goal is to use less restrictive interventions first to manage the client's behaviour.

A. Apply soft restraints to all extremities. B. Remove objects that could cause injury. C. Place pillows around the client's head. D. Administer oxygen per nasal cannula.

Correct Answer is B

Explanation

Choice A reason: Applying soft restraints to all extremities is not appropriate during a seizure as it can increase the risk of injury. The priority is to ensure the client's safety by preventing injury without restraining them.

Choice B reason: Removing objects that could cause injury is crucial. During a seizure, the client may move unpredictably, and any nearby objects could pose a risk of harm. Clearing the area ensures the client has a safe space to have the seizure without additional hazards.

Choice C reason: Placing pillows around the client's head can provide some protection, but it is not as immediately effective or necessary as removing potentially harmful objects from the surrounding area. Ensuring a clear and safe environment is the primary concern.

Choice D reason: Administering oxygen per nasal cannula is not the first priority during a seizure. While maintaining oxygenation is important, the immediate focus should be on ensuring the client's physical safety by removing dangerous objects. Once the seizure subsides, appropriate respiratory support can be provided if needed.

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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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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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