Exhibits
After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?
Perform pulmonary function test
Measure vital signs
Apply oxygen 1 L/minute
Give albuterol as ordered
Provide a regular diet tray
Correct Answer : C,D
Based on the client’s current condition and the urgency of the interventions, the nurse should complete the following prescriptions first:
- C) Apply oxygen 1 L/minute: The client’s oxygen saturation level needs to be kept above 94%. Given her difficulty in breathing and the fact that she is pale and sitting upright, it’s crucial to ensure she is receiving enough oxygen.
- D) Give albuterol as ordered: Albuterol is a bronchodilator that can help relieve the client’s asthma symptoms. Since her symptoms did not resolve after taking her usual dose of albuterol, administering another dose as ordered can help improve her breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","F","H"]
Explanation
H.
Choice A rationale
Monitoring the oxygen saturation is an important nursing intervention following the administration of albuterol. Albuterol is a bronchodilator and should improve oxygen saturation by increasing airflow and oxygen delivery.
Choice B rationale
Deep tracheal suctioning is not typically required following the administration of albuterol unless the patient has excessive secretions or difficulty clearing secretions.
Choice C rationale
Discussing potential asthma triggers with the client is an important nursing intervention. Understanding and avoiding triggers can help prevent future asthma exacerbations.
Choice D rationale
Obtaining a sputum culture is not typically required following the administration of albuterol unless there is a suspicion of a respiratory infection.
Choice E rationale
Positive pressure ventilation is not typically required following the administration of albuterol unless the patient is in severe respiratory distress.
Choice F rationale
Allowing the client to take a position of comfort can help improve breathing and should be encouraged.
Choice G rationale
Discussing aggressive respiratory treatment options is not typically required following the administration of albuterol unless the patient’s condition is not improving or worsening.
Choice H rationale
Weaning the supplemental oxygen may be appropriate following the administration of albuterol if the patient’s oxygen saturation has improved.
Correct Answer is A
Explanation
Choice A rationale
The patient’s history indicates that she had difficulty breathing during a hike. This event led her to the emergency department. Difficulty breathing during physical activity such as hiking can be a symptom of an asthma exacerbation.
Choice B rationale
While severe allergic reactions can cause difficulty breathing, the patient’s history does not indicate that she experienced an allergic reaction prior to her emergency department visit.
Choice C rationale
Panic attacks can cause symptoms such as rapid heart rate, sweating, and shortness of breath. However, the patient’s history does not indicate that she had a panic attack prior to her emergency department visit.
Choice D rationale
Fainting, or loss of consciousness, can be caused by various conditions, including dehydration, low blood sugar, and heart problems. However, the patient’s history does not indicate that she fainted prior to her emergency department visit.
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