Following the administration of albuterol and the subsequent assessment, what actions should the nurse plan for the rest of the shift?
Monitor the oxygen saturation
Prepare for deep tracheal suctioning
Discuss potential asthma triggers with the client
Obtain a sputum culture
Consider positive pressure ventilation
Allow the client to take a position of comfort
Discuss aggressive respiratory treatment options
Wean the supplemental oxygen .
Correct Answer : A,C,F,H
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Production of extra platelets is not the primary pathophysiological process in Disseminated Intravascular Coagulation (DIC). While the body may try to produce more platelets in response to the widespread clotting, this is not the cause of the coagulation problem.
Choice B rationale
Depletion of clotting factors is a key feature of DIC. In the initial phase of DIC, there is an overactive clotting process leading to the formation of small blood clots throughout the body’s blood vessels. This overactive clotting uses up platelets and clotting factors, leading to a state where the body is unable to control bleeding, which is the second phase of DIC34.
Choice C rationale
Inhibition of red blood cell production is not a primary feature of DIC. While DIC can lead to anemia due to blood loss from excessive bleeding, it does not directly inhibit the production of red blood cells.
Choice D rationale
Activation of complement pathways is part of the body’s immune response and is not the primary cause of the coagulation problem in DIC34.
Correct Answer is C,A,D,B
Explanation
Step 1: Observe breathing patterns. Respiratory depression is a critical symptom of myxedema coma that requires immediate attention.
Step 2: Measure body temperature. Hypothermia is a common symptom of myxedema coma and can provide important information about the severity of the patient’s condition.
Step 3: Assess blood pressure. Hypotension can occur in myxedema coma and can indicate the severity of the patient’s condition.
Step 4: Palpate for pedal edema. While this can be a symptom of hypothyroidism, it is not typically a primary concern in a patient showing signs of myxedema coma.
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