Exhibits
Which physical sign most strongly supports the nurse's concern for worsening asthma?
Normal temperature
Slightly elevated heart rate
Nasal flaring and intercostal retractions
Use of maintenance inhaler
The Correct Answer is C
A. Normal temperature: A temperature of 98.6°F (37°C) is within the normal range and does not contribute to the assessment of asthma severity. It helps rule out infection but does not reflect worsening respiratory status.
B. Slightly elevated heart rate: A heart rate of 122 bpm is elevated for a 7-year-old and may indicate respiratory distress or anxiety. However, it is a nonspecific finding and not the strongest indicator of worsening asthma.
C. Nasal flaring and intercostal retractions: These are classic signs of increased work of breathing and indicate significant respiratory distress. They reflect worsening airway obstruction and the need for immediate intervention to prevent further deterioration.
D. Use of maintenance inhaler: Use of a maintenance inhaler such as fluticasone is part of routine asthma management and does not indicate worsening symptoms. It is a preventive measure, not a reflection of acute status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Retractions on assessment:Retractions suggest increased respiratory effort and are a sign of respiratory distress. Their presence indicates that the airway is still obstructed or the patient is struggling to breathe, suggesting the bronchodilator has not been effective.
B. Chest tightness:Chest tightness is a subjective symptom often associated with bronchospasm or airway constriction. If it persists after bronchodilator use, it signals continued respiratory compromise and inadequate relief from the medication.
C. Use of accessory muscles:Use of accessory muscles indicates labored breathing and ongoing difficulty with ventilation. Effective bronchodilation should reduce the work of breathing and minimize reliance on these muscles.
D. SpO₂ increased from 87% to 94%:An increase in oxygen saturation indicates improved gas exchange and oxygenation, reflecting that the bronchodilator has successfully opened the airways. This is a measurable and objective sign of medication effectiveness.
Correct Answer is A
Explanation
A. Vitamin K:Vitamin K is the antidote for warfarin overdose. Warfarin inhibits vitamin K-dependent clotting factors, and administering vitamin K reverses this effect by promoting the synthesis of clotting factors to control bleeding.
B. Magnesium sulfate:Magnesium sulfate is used to treat conditions such as torsades de pointes and eclampsia but has no role in reversing the anticoagulant effects of warfarin. It does not impact coagulation pathways or vitamin K levels.
C. Flumazenil:Flumazenil is an antidote for benzodiazepine overdose. It acts by antagonizing the effects of drugs like diazepam and lorazepam but has no effect on warfarin or anticoagulation reversal.
D. Protamine sulfate:Protamine sulfate is the antidote for heparin and low-molecular-weight heparin overdose, not warfarin. It neutralizes heparin's anticoagulant properties but does not interact with vitamin K or affect warfarin action.
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