Exhibits
The Correct Answer is []
Rationale for Correct Choices:
• Place on Oxygen: The client’s oxygen saturation dropped to 85% on room air, indicating hypoxemia. Supplemental oxygen is required immediately to maintain levels above 93% and prevent worsening respiratory failure. This is consistent with the provider’s orders and emergent asthma care protocols.
• Administer Albuterol: Albuterol is a rapid-acting beta-2 agonist bronchodilator that relieves airway constriction in acute asthma. It directly addresses the wheezing, chest tightness, and severe shortness of breath. Frequent nebulized doses are recommended in status asthmaticus.
• Status Asthmaticus: This is a severe, life-threatening asthma exacerbation unresponsive to initial bronchodilator therapy. The client’s confusion, tachypnea, hypoxemia, and inability to speak in full sentences are classic signs. Without prompt treatment, it can progress to respiratory arrest.
• Pulse Oximetry : Continuous pulse oximetry helps track oxygenation and the effectiveness of interventions. Given the hypoxemia, frequent monitoring is essential to prevent respiratory arrest.
• Respirations Respiratory rate and pattern reflect both asthma severity and the client’s progression toward respiratory fatigue. Worsening asthma can cause sudden respiratory rate drops as exhaustion sets in.
Rationale for Incorrect Choices:
• Suction Airway: There is no evidence of excessive secretions or mucus plugging; the main issue is bronchospasm and airway narrowing, not obstruction from secretions.
• Administer a Diuretic: Diuretics treat fluid overload (e.g., pulmonary edema), which is not present here. This client’s symptoms stem from asthma, not heart failure or volume excess.
• Obtain Sputum Culture: This is done if infection is suspected; the client denies fever and shows no purulent sputum production. This is an acute asthma exacerbation, not pneumonia.
• Anaphylactic Reaction: While both involve airway compromise, there are no signs of urticaria, hypotension, or sudden onset after allergen exposure. This client’s symptoms developed over 2–3 days.
• Pulmonary Edema: Pulmonary edema causes crackles, frothy sputum, and fluid overload symptoms, none of which are present. This client’s lung sounds are wheezy, not wet.
• RSV: RSV is a viral respiratory infection more common in infants and young children; the presentation and history point to asthma, not viral bronchiolitis.
• Troponin: Troponin measures cardiac injury, which is not suspected here. The client’s tachycardia is secondary to respiratory distress, not myocardial infarction.
• Urine Output: While urine output is important in some critical conditions, it is not the primary priority in acute asthma management.
• Temperature: There is no indication of infection or hyperthermia; temperature monitoring is routine but not a key focus in this acute situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. The child's fluid and salt intake will be restricted until after surgery: Fluid and salt restrictions are not standard for Wilm’s tumor unless the child has concurrent kidney failure or hypertension. Most children maintain normal fluid and electrolyte management.
B. The child's abdomen is not to be palpated, and handling must be gentle: Wilm’s tumor is a kidney tumor that is often encapsulated. Palpation of the abdomen can risk rupturing the tumor capsule, which could lead to tumor seeding in the abdominal cavity and worsening prognosis.
C. Touching or holding the child requires the person to don a gown and mask: Gowns and masks are used for infection control in cases of contagious illness or in immunocompromised patients, not for the presence of a tumor.
D. Blood pressure readings are not to be taken on the left arm: Blood pressure restrictions on a specific arm are usually related to vascular access devices (like PICC lines) or conditions involving circulation in that arm. Wilm’s tumor does not require avoidance of BP measurements on a particular arm unless there is a separate vascular concern.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Rationale for Correct Choices:
• Weak: Weak pedal pulses are typical because the narrowed aortic segment reduces blood flow to the lower extremities. This is a key clinical finding that often leads to suspicion of coarctation in children.
• Strong: Brachial pulses are typically strong or bounding because the narrowing occurs after the vessels to the upper body branch off, allowing normal or increased perfusion to the arms.
Rationale for Incorrect Choices:
• Absent: Completely absent pedal pulses are uncommon in coarctation of the aorta unless the narrowing is extremely severe or there is complete arterial obstruction. Most clients will have diminished but still palpable pedal pulses.
• Bounding: Bounding pedal pulses would indicate increased blood flow to the lower extremities, which is not seen in coarctation of the aorta. Instead, bounding pulses are usually found in the upper extremities in this condition.
• Weak: Weak brachial pulses would suggest reduced blood flow to the upper extremities, which is inconsistent with the anatomy of coarctation where the narrowing is distal to these branches.
• Thready: Thready pulses indicate low stroke volume or shock states, which are not characteristic of compensated coarctation. In coarctation, upper extremity pulses remain strong unless severe heart failure develops.
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