Exhibits
The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, which action(s) should the nurse anticipate? Select all that apply.
Administer medications as prescribed.
Ask the client for a list of current medications.
Notify the healthcare provider of the client's need for intubation.
Apply oxygen via nasal cannula.
Provide client teaching.
Place the client in Trendelenburg position.
Correct Answer : A,D,E
A. Administer medications as prescribed. This includes the albuterol/ipratropium nebulizer treatment and oral prednisone, which are essential for managing acute asthma exacerbations.
B. Ask the client for a list of current medications: While this information is important, it is not the immediate priority in managing an acute asthma exacerbation.
C. Notify the healthcare provider of the client's need for intubation: Intubation is a more invasive procedure and is typically reserved for severe cases of respiratory distress that are not responding to medical therapy. In this case, the client's condition is not severe enough to warrant immediate intubation.
D. Apply oxygen via nasal cannula. The client's oxygen saturation is below 94%, indicating hypoxemia, and supplemental oxygen is necessary to improve oxygenation.
E. Provide client teaching. This includes educating the client about asthma triggers, medication adherence, and early signs of an asthma exacerbation.
F. Place the client in Trendelenburg position: This position is not indicated for asthma exacerbations. It is typically used for conditions like shock or hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
Pain at the affected joint
- Acute gout attack: Yes. During an acute gout attack, the pain is typically sudden, intense, and localized to one joint, often the big toe.
- Chronic gout: No. Chronic gout usually involves recurrent attacks over time, but the pain at any given moment may not be as intense or localized to a single joint unless there is a flare-up.
2. Low grade fever
- Acute gout attack: Yes. During an acute attack, inflammation caused by uric acid crystals can lead to mild fever (100°F to 101°F).
- Chronic gout: No. Chronic gout usually does not cause fever unless there is a secondary infection or other complicating factor.
3. Occurs in more than 1 joint
- Acute gout attack: No. Typically, an acute gout attack involves only one joint, especially the big toe (podagra).
- Chronic gout: Yes. Over time, gout can involve multiple joints, especially with untreated or poorly managed cases.
4. Renal dysfunction
- Acute gout attack: No. Acute gout attacks generally do not cause renal dysfunction.
- Chronic gout: Yes. Chronic gout can lead to kidney damage or urate nephropathy due to long-term hyperuricemia and uric acid crystal deposition in the kidneys.
5. Visible tophi
- Acute gout attack: No. Tophi, which are uric acid crystal deposits under the skin, typically appear in later stages of gout, not during an acute attack.
- Chronic gout: Yes. Visible tophi are a characteristic feature of chronic gout and occur after repeated and prolonged gout attacks, leading to the accumulation of uric acid crystals in soft tissues.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}
Explanation
Indicates the Interventions Were Successful:
- Client can now speak in full sentences without pausing. This shows an improvement in the client's breathing and overall respiratory function.
- Respirations 16 breaths/minute. This is a normal respiratory rate, indicating that the client's breathing has stabilized.
No Indication that the Interventions Were Successful:
- Blood pressure 122/84 mmHg. While this is a normal blood pressure reading, it does not specifically indicate the success of the interventions for an asthma attack.
- Heart rate 105 beats/minute. Although slightly improved, this heart rate is still elevated and does not clearly indicate the success of the interventions.
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