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 ["C","D","E","F","G","H","J"]
Explanation
Based on the provided information, the following assessment findings require immediate follow-up by the nurse:
- Difficulty breathing on a hike: This is a significant symptom of asthma exacerbation and needs immediate attention.
- Symptoms did not resolve after taking albuterol: Albuterol is a quick-relief medication for asthma symptoms. If symptoms do not improve after its use, it indicates that the asthma exacerbation is severe.
- Mild subcostal retractions: This is a sign of respiratory distress and indicates that the client is using accessory muscles to breathe.
- Wheezes noted throughout the lung fields: Wheezing is a common sign of asthma and indicates airway obstruction.
- The client is pale: Paleness can be a sign of decreased oxygenation.
- Heart rate of 122 beats/minute: A high heart rate can be a sign of distress or could be due to the body’s attempt to compensate for decreased oxygenation.
- Oxygen saturation of 91% on room air: Normal oxygen saturation is typically 95% or higher. A saturation of 91% indicates that the client is not getting enough oxygen.
Correct Answer is C
Explanation
Choice A rationale
While the frequency of a problem can provide some context, it is not the most important consideration when gathering evidence for evidence-based decision-making. The frequency of a problem does not necessarily correlate with the quality or relevance of the evidence available.
Choice B rationale
Personal values are important in decision-making processes, but they are subjective and can vary greatly among individuals. Therefore, they are not the most important consideration when gathering objective, scientific evidence for evidence-based practice.
Choice C rationale
Relevance to the situation is the most important consideration when gathering evidence. Evidence must be directly applicable to the specific problem and context in order to be useful in informing decision-making. This includes considering the specific characteristics of the patient population, the nature of the problem, and the setting in which care is being provided.
Choice D rationale
Past experience with similar problems can provide valuable insights and context, but it is not the most important consideration. Past experiences are individual and subjective, and what worked in one situation may not work in another. Evidence-based practice requires the use of current, high-quality research evidence, which may or may not align with past experiences.
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