After initiating a steroid nebulizer treatment for a client with asthma in respiratory distress, which intervention is most important for the nurse to implement?

Monitor pulse oximetry every 2 hours.

Teach proper use of a rescue inhaler.

Elevate the head of bed to 90 degrees.

Determine exposure to asthmatic triggers.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is incorrect because monitoring pulse oximetry every 2 hours is not a sufficient or timely intervention for the nurse to implement. Pulse oximetry is a noninvasive method of measuring the oxygen saturation of hemoglobin in the blood. Normal oxygen saturation is 95% to 100%, while hypoxemia is less than 90%. However, pulse oximetry may not reflect the severity of respiratory distress or the effectiveness of nebulizer treatment in a client with asthma. Moreover, monitoring pulse oximetry every 2 hours is too infrequent for a client who is in acute respiratory distress and needs more frequent assessment and intervention.

Choice B reason: This is incorrect because teaching proper use of a rescue inhaler is not a priority or relevant intervention for the nurse to implement. A rescue inhaler is a type of short-acting bronchodilator that can be used to relieve acute asthma symptoms by relaxing the smooth muscles of the airways and improving airflow. However, teaching proper use of a rescue inhaler is not an urgent action for a client who is already receiving nebulizer treatment, which delivers a higher dose of medication directly to the lungs. Moreover, teaching proper use of a rescue inhaler is not appropriate for a client who is in respiratory distress and may not be able to focus or retain information.

Choice C reason: This is correct because elevating the head of bed to 90 degrees is the most important intervention for the nurse to implement. Elevating the head of bed to 90 degrees can help improve breathing and oxygenation by reducing pressure on the diaphragm and chest wall, increasing lung expansion and ventilation, and facilitating expectoration of mucus. This can enhance the effects of nebulizer treatment and reduce respiratory distress in a client with asthma.

Choice D reason: This is incorrect because determining exposure to asthmatic triggers is not an immediate or helpful intervention for the nurse to implement. Asthmatic triggers are substances or factors that can cause or worsen asthma symptoms by inducing inflammation or constriction of the airways. Examples of asthmatic triggers include allergens, irritants, infections, exercise, stress, or weather changes. However, determining exposure to asthmatic triggers is not a priority action for a client who is in respiratory distress and needs more urgent interventions to improve breathing and oxygenation. Moreover, determining exposure to asthmatic triggers may not change the management or outcome of an acute asthma attack that has already occurred.

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Correct Answer is B

Explanation

Choice A reason: The humoral immune response is mediated by B cells that produce antibodies against specific antigens. However, this response is not the main problem in AIDS, because B cells are not directly affected by the human immunodeficiency virus (HIV) that causes AIDS. Therefore, this choice is incorrect.

Choice B reason: The cellular immune response is mediated by T lymphocytes that activate other immune cells, such as macrophages, to destroy infected or abnormal cells. This response is the main problem in AIDS, because HIV infects and destroys CD4+ T cells, which are essential for coordinating the cellular immunity. As a result, the client becomes susceptible to opportunistic infections, such as Pneumocystis jiroveci pneumonia. Therefore, this choice is correct.

Choice C reason: Bone marrow suppression of white blood cells can cause immunodeficiency, but it is not the primary cause of AIDS. Bone marrow suppression can occur as a side effect of some drugs or treatments, such as chemotherapy or radiation therapy, but it is not directly caused by HIV. Therefore, this choice is incorrect.

Choice D reason: Exposure to multiple environmental infectious agents can challenge the immune system, but it does not necessarily cause it to fail. The immune system can adapt and respond to different pathogens, unless it is compromised by an underlying condition, such as AIDS. Therefore, this choice is incorrect.

A. Sweet potatoes. B. Spinach salad. C. Bananas. D. Fish.

Correct Answer is B

Explanation

Choice A reason: Sweet potatoes are not a food that the client should avoid after passing a calcium oxalate renal stone, because they are low in oxalate, which is a substance that can combine with calcium in the urine and form stones. The client should limit foods that are high in oxalate, such as spinach, rhubarb, beets, nuts, chocolate, tea, and wheat bran. Therefore, this choice is incorrect.

Choice B reason: Spinach salad is a food that the client should avoid after passing a calcium oxalate renal stone, because it is high in oxalate, which can increase the risk of stone formation. The client should consume foods that are low in oxalate, such as rice, corn, apples, grapes, peaches, and cheese. Therefore, this choice is correct.

Choice C reason: Bananas are not a food that the client should avoid after passing a calcium oxalate renal stone, because they are low in oxalate and high in potassium, which can help prevent stone formation. The client should increase the intake of fluids, calcium, and citrate, which can reduce the concentration of oxalate and calcium in the urine and inhibit stone formation. Therefore, this choice is incorrect.

Choice D reason: Fish is not a food that the client should avoid after passing a calcium oxalate renal stone, because it is low in oxalate and high in protein, which can help maintain muscle mass and prevent weight loss. The client should moderate the intake of animal protein, such as meat, poultry, eggs, and dairy products, which can increase the acidity of the urine and promote stone formation. Therefore, this choice is incorrect.

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After initiating a steroid nebulizer treatment for a client with asthma in respiratory distress, which intervention is most important for the nurse to implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

Correct Answer is B

Explanation

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