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 B
Explanation
A. Avoiding frequent eye pressure measurements is not advisable; monitoring eye pressure is crucial in managing glaucoma.
B. Maintaining the prescribed eye drop regimen is the most important instruction because consistent use of these medications is critical to managing intraocular pressure and preventing vision loss associated with glaucoma.
C. While wearing prescription glasses can assist with vision, it does not address the underlying condition of glaucoma.
D. Eating a diet high in carotene is beneficial for overall eye health but does not directly impact the management of glaucoma. Regular use of prescribed eye drops is essential to prevent further damage to the optic nerve and potential blindness.
Correct Answer is D
Explanation
A. Administering aspirin is not appropriate at this time, as it may delay treatment for a stroke if that is the underlying cause.
B. Maintaining elevated positioning of the dependent joints is not a priority in this acute situation and does not address the immediate needs of the client showing signs of possible stroke.
C. Verifying laboratory tests like prothrombin time and platelet count is important but is not an immediate intervention that addresses the acute condition.
D. Starting two large bore IV catheters and reviewing criteria for IV fibrinolytic therapy is crucial because the client presents with signs of a potential stroke. Rapid identification and treatment are essential to improving outcomes in acute ischemic stroke cases.
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