Patient Data

After the nurse assesses the client, the healthcare provider (HCP) writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

Give albuterol as prescribed

Provide a regular diet tray

Perform pulmonary function test

Apply oxygen 1 L/minute

Measure vital signs

Answer and Explanation

Correct Answer : A,D

Brief introduction:

Asthma involves chronic airway inflammation and hyperresponsiveness leading to reversible bronchoconstriction. During an acute exacerbation, triggers like exercise or viral infections cause smooth muscle contraction, mucosal edema, and mucus plug formation. This increases airway resistance and reduces ventilation-perfusion ratios, causing hypoxemia and tachypnea.

Rationale:

A. Administering a short-acting beta-2 agonist like albuterol is a priority to reverse acute bronchospasm. This medication rapidly stimulates beta receptors in the lungs to induce bronchial relaxation. Opening the airways facilitates gas exchange and reduces the work of breathing during a severe asthma attack.

B. Providing a regular diet tray is a non-urgent intervention and should be delayed. The client is currently experiencing respiratory distress and has difficulty speaking, making oral intake a secondary concern. Focusing on nutritional support before stabilizing the patient’s airway and oxygenation status is inappropriate clinical practice.

C. Pulmonary function tests are diagnostic tools used to assess lung capacity but are not for acute management. Attempting these tests while a patient is actively wheezing and pale could worsen respiratory fatigue. Initial treatment must focus on immediate physiological stabilization rather than gathering baseline long-term diagnostic data.

D. Oxygen therapy must be initiated immediately to treat cellular hypoxia indicated by an oxygen saturation of 91%. Restoring oxygen levels protects vital organs from ischemic damage while pharmacological agents work to open the constricted airways. Maintenance of saturation >94% ensures adequate peripheral tissue oxygenation during respiratory distress.

E. While monitoring vital signs is important, it is an assessment rather than a stabilizing intervention. In an emergency, the nurse should prioritize actions that directly treat the underlying pathology of hypoxia and bronchoconstriction. Life-saving treatments like albuterol and oxygen must precede the routine documentation of circulatory and respiratory rates.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"C"}

Explanation

In fetal circulation, the ductus arteriosus is a vital vascular structure that shunts blood from the pulmonary artery to the aorta, bypassing the non-functional fetal lungs. Shortly after birth, rising systemic oxygen levels and the withdrawal of placental prostaglandins normally trigger the closure of this vessel. In preterm infants (such as this 32-week newborn), the musculature of the ductal wall is often underdeveloped, leading to a failure of closure and the persistence of this fetal shunt.

Rationale:

Acyanotic: In this defect, blood shunts from a high-pressure area (aorta) to a lower-pressure area (pulmonary artery). Because oxygenated blood is being recirculated back to the lungs rather than deoxygenated blood entering the systemic circulation, the infant typically remains pink (acyanotic) unless the defect is extremely large or leads to heart failure.

Patent ductus arteriosus (PDA): The echocardiogram specifically noted "left-to-right flow noted from aorta to pulmonary artery." This is the definitive diagnostic description of a PDA. PDA is highly common in infants born at 32 weeks gestation due to immature ductal tissue. Tetralogy of Fallot is a cyanotic defect involving right-to-left shunting. Pulmonary stenosis is an obstructive defect that usually results in decreased pulmonary flow.

Increased pulmonary flow: Since the "hole" (ductus) connects the high-pressure aorta to the lower-pressure pulmonary artery, extra blood is forced into the pulmonary circulation. This explains the "diffuse fluid noted bilaterally" on the chest x-ray (pulmonary congestion) and the mild tachypnea (respiratory rate of 65). The lungs are essentially being over-perfused, which can lead to respiratory distress and pulmonary edema.

A. Position infant with head of bed elevated B. Gavage feed infant C. Administer spironolactone as prescribed D. Repeat blood glucose level E. Administer furosemide as prescribed

Correct Answer is ["A","B","E"]

Explanation

The management of a 32 week neonate with patent ductus arteriosus (PDA) focuses on reducing pulmonary overcirculation and conserving energy. Pharmacological diuresis and proper positioning are essential to alleviate the respiratory distress caused by left-to-right shunting and subsequent pulmonary edema.

Rationale:

A. Elevating the head of the bed (HOB) to 30 to 45 degrees promotes maximum diaphragmatic excursion and reduces the work of breathing. This position uses gravity to keep abdominal contents from pressing against the diaphragm, which is critical for a neonate experiencing tachypnea and pulmonary congestion. It helps optimize lung expansion and oxygenation in the presence of diffuse pulmonary fluid.

B. Preterm infants with respiratory rates > 60 breaths/minute are at high risk for aspiration and excessive energy expenditure during oral feedings. Gavage feeding allows for the delivery of 60 mL breast milk while minimizing cardiac demands and the risk of respiratory compromise. This method ensures the infant receives essential nutrients without increasing the metabolic workload associated with sucking and swallowing.

C. While spironolactone is a potassium-sparing diuretic, it has a slow onset of action and is generally not the acute priority in the initial management of pulmonary congestion. Its role is typically for long-term fluid maintenance rather than the rapid diuresis needed for an infant with coarse lung sounds and tachypnea. The nurse should prioritize the fast-acting loop diuretic over this medication in the immediate clinical window.

D. The infant’s blood glucose is 48 mg/dL, which falls within the documented reference range of 30 to 60 mg/dL. Since the infant is not hypoglycemic and is receiving regular enteral nutrition via the prescribed 60 mL breast milk, a repeat glucose level is not an immediate priority. The nurse should focus on the cardiopulmonary instability caused by the echocardiogram findings and respiratory symptoms instead.

E. Furosemide is a potent loop diuretic indicated for the management of pulmonary edema associated with PDA-induced congestive heart failure. By inhibiting sodium reabsorption, it rapidly reduces circulating volume and alleviates the diffuse bilateral fluid noted on the chest x-ray. Reducing preload is a primary intervention to improve respiratory mechanics and decrease the burden on the immature heart.

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Patient Data After the nurse assesses the client, the healthcare provider (HCP) writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"C"}

Explanation

The nurse is considering appropriate interventions for this client. Select 3 interventions that are priority for this client.

Correct Answer is ["A","B","E"]

Explanation

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Patient Data

After the nurse assesses the client, the healthcare provider (HCP) writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?