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Exhibits

The nurse starts the albuterol nebulizer as prescribed.

Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.

Temperature

Breath sounds

Complete blood count

Heart rate

Peak inspiratory flow

Serum sodium

Peak expiratory flow

Oxygen saturation

Answer and Explanation

Correct Answer : A,B,D,G,H

A.   Assessing temperature is important to monitor for any signs of infection or inflammation, which could exacerbate the asthma condition or indicate a concurrent illness.
B.   Evaluating breath sounds helps determine the effectiveness of the albuterol treatment in relieving bronchospasm. Clearer breath sounds suggest improved air entry and reduced wheezing.
C.   While CBC can provide valuable information, it is not typically immediately necessary after an albuterol treatment unless there are specific concerns about infection or other systemic issues.
D.   Monitoring the heart rate is crucial as albuterol can cause tachycardia (elevated heart rate) as a side effect. It's important to ensure that the heart rate does not become excessively elevated, which may indicate a need to adjust treatment or monitor more closely.
E.   Peak inspiratory flow is less commonly used in asthma management compared to peak expiratory flow. It's the maximum flow rate during inhalation and is not typically assessed routinely in the immediate post-treatment period.
F.   Assessing serum sodium is not directly related to monitoring asthma exacerbation or response to bronchodilator therapy.
G.   PEF measures the maximum speed at which a person can exhale air after a deep breath. It is a direct indicator of lung function and the severity of airway obstruction in asthma. Assessing PEF post-albuterol treatment helps gauge how well the airways have responded to the bronchodilator therapy.
H.   Checking oxygen saturation ensures that the patient's oxygen levels have improved following the administration of albuterol. The goal is to maintain oxygen saturation above 94%, as per the treatment plan.

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Correct Answer is C

Explanation

Rationale

A. The client's friend may not legally be authorized to provide consent unless they hold medical power of attorney or legal guardianship for the client. Without documentation of such authority, the friend cannot sign the informed consent.

B. In emergency situations where a patient lacks decision-making capacity and there is no available legal guardian or next of kin to provide consent, hospitals may seek a court order to proceed with necessary treatment. However, this could delay emergency treatment.

C. This is based on the legal and ethical understanding that saving the patient's life takes precedence when immediate action is required and consent cannot be obtained.

D. Providing life support ensures that the client's immediate medical needs are addressed while efforts are made to locate a legal guardian. However, unavailability of next of kin should not delay definitive intervention

A. Verify troponin level assessments are scheduled every 3 to 6 hours for a series of three. B. Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area. C. Count and record the number of premature ventricular contractions per minute. D. Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%.

Correct Answer is D

Explanation

Rationale

A. Troponin levels are cardiac biomarkers that are elevated in the blood when there is damage to the heart muscle, such as during a myocardial infarction (heart attack). Verifying the schedule for troponin assessments is important to monitor for myocardial damage and to guide treatment decisions.

B. This action is aimed at creating a quiet and calm environment for the client, which can help reduce anxiety and minimize stimuli that might exacerbate symptoms. Creating a conducive environment is beneficial for the client's comfort and well-being but should not delay urgent interventions required for acute symptoms.

C. PVCs are abnormal heartbeats that can occur in individuals with CAD and may indicate increased cardiac irritability or instability. While monitoring PVCs is important for assessing cardiac rhythm and potential complications, it is not the immediate priority over addressing acute symptoms such as shortness of breath, nausea, and chest pressure.

D. Oxygen therapy is essential in the management of a client with suspected ACS to improve oxygenation and reduce cardiac workload. Maintaining oxygen saturation above 93% helps ensure adequate tissue oxygenation, especially during episodes of chest discomfort and potential myocardial ischemia.

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Exhibits The nurse starts the albuterol nebulizer as prescribed. Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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Exhibits

The nurse starts the albuterol nebulizer as prescribed.

Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.