While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed lip breathing. Which intervention should the nurse implement?

Increase oxygen to 6 liters/minute.

Call for an Ambu resuscitation bag.

Instruct the client to lie back in bed.

Administer a nebulizer treatment.

Answer and Explanation

The Correct Answer is D

Choice A reason: Increasing oxygen to 6 liters/minute is not an intervention that the nurse should implement, as this can worsen the bronchospasm and hypoxia by reducing the hypoxic drive and causing carbon dioxide retention. This is a contraindicated choice.

Choice B reason: Calling for an Ambu resuscitation bag is not an intervention that the nurse should implement, as this is not indicated for a client who is conscious and breathing spontaneously. This is an overreaction choice.

Choice C reason: Instructing the client to lie back in bed is not an intervention that the nurse should implement, as this can increase respiratory distress and compromise airway clearance by reducing lung expansion and increasing abdominal pressure. This is another contraindicated choice.

Choice D reason: Administering a nebulizer treatment is an intervention that the nurse should implement, as this can deliver bronchodilators and anti-inflammatory agents directly to the airways and improve ventilation and oxygenation for this client. Therefore, this is the correct choice.

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Correct Answer is A

Explanation

Choice A reason: applying the client's positive airway pressure device can help prevent or reduce episodes of apnea and hypopnea during sleep by keeping the airway open and delivering oxygen. The nurse should ensure that the device fits properly and that the client knows how to use it.

Choice B reason: elevating the head of the bed to a 45 degree angle is not as effective as using a positive airway pressure device for a client with OSA. Elevating the head of the bed may help reduce snoring and improve breathing, but it may not prevent airway collapse or oxygen desaturation.

Choice C reason: removing dentures or other oral appliances is not as important as applying a positive airway pressure device for a client with OSA. Removing dentures or other oral appliances may help prevent choking or aspiration, but it may not prevent airway collapse or oxygen desaturation.

Choice D reason: lifting and locking the side rails in place is not as important as applying a positive airway pressure device for a client with OSA. Lifting and locking the side rails in place may help prevent falls or injuries, but it may not prevent airway collapse or oxygen desaturation.

A. Measure abdominal girth B. Assess perineal area C. Observe insertion site D. Palpate flank area

Correct Answer is C

Explanation

Choice A reason: Measuring abdominal girth is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be useful for monitoring fluid status and abdominal distension.

Choice B reason: Assessing perineal area is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be important for maintaining hygiene and preventing infection.

Choice C reason: This is the correct answer because observing insertionsite is a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. The nurse should inspect the incision site for signs of healing, infection, or leakage.

Choice D reason: Palpating flank area is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be helpful for detecting kidney tenderness or enlargement.

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Naxlex Comprehensive Predictor Exams

A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?

Correct Answer is A

Explanation

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is C

Explanation

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement?(Select all that apply.)