An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?
Coughing
Flat neck veins
Use of accessory muscles
Presence of coarse crackles
The Correct Answer is C
Rationale:
A. Coughing: While coughing is a common symptom of asthma, it is not specific to status asthmaticus. It can occur during mild, moderate, or severe asthma episodes and does not necessarily indicate life-threatening severity.
B. Flat neck veins: Flat neck veins are not characteristic of status asthmaticus. In severe respiratory distress, the client may show signs of increased intrathoracic pressure, which can lead to distended neck veins rather than flat ones.
C. Use of accessory muscles: The use of accessory muscles to breathe is a sign of severe respiratory distress and indicates that the client is struggling to maintain adequate ventilation. This is a hallmark of status asthmaticus, a life-threatening condition requiring immediate intervention.
D. Presence of coarse crackles: Coarse crackles are more commonly associated with fluid in the lungs, such as in pneumonia or heart failure. In status asthmaticus, breath sounds may be diminished or absent due to severe airway obstruction, rather than producing crackles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Report of itching: Itching is a common early sign of an allergic transfusion reaction. These reactions occur due to sensitivity to plasma proteins in the donor blood and may also present with hives, flushing, or mild respiratory symptoms.
B. Distended jugular veins: Jugular vein distention is a sign of fluid overload or circulatory compromise, such as transfusion-associated circulatory overload (TACO), not an allergic reaction.
C. Report of low back pain: Low back pain is more indicative of an acute hemolytic reaction, which results from ABO incompatibility. This is a serious and life-threatening reaction distinct from allergic responses.
D. Temperature 37.8° C (100° F): A mild elevation in temperature may be seen with febrile non-hemolytic transfusion reactions, which are different from allergic reactions. Allergic reactions usually involve skin and respiratory symptoms.
Correct Answer is C
Explanation
Rationale:
A. Notify the surgeon of the temperature elevation: While the surgeon may need to be informed if there are signs of infection or persistent fever, the nurse should first gather more data to determine the possible cause of the elevated temperature.
B. Encourage the client to drink more fluids: Increased fluid intake may help reduce mild postoperative fever, especially if it's related to dehydration or atelectasis. However, this is not the priority without assessing for infection first.
C. Assess the surgical incision for signs of infection: The priority is to assess for potential sources of infection, particularly the surgical site, given that the client is 3 days postoperative and has a fever. Early identification of infection is critical to prevent complications such as wound dehiscence or sepsis.
D. Monitor vital signs every 4 hr: Routine monitoring is important but does not take precedence over immediate assessment of the surgical site when there is a concerning temperature elevation. The nurse should act to identify the cause first.
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