Sara is receiving a nebulized albuterol treatment for her asthma exacerbation. Which of the following should be the nurse’s first priority after administering the treatment?
Auscultate Sara’s lung sounds.
Measure Sara’s temperature.
Encourage Sara to ambulate
Document the treatment in her medical record.
The Correct Answer is A
Choice A reason: Auscultating lung sounds post-albuterol assesses treatment efficacy in asthma exacerbation. Reduced wheezing or improved air entry indicates bronchodilation, guiding further care, making it the priority to evaluate respiratory response immediately.
Choice B reason: Measuring temperature monitors infection, a possible asthma trigger, but it’s not the priority post-treatment. Albuterol targets acute bronchospasm, so assessing respiratory effect trumps systemic checks like fever in this moment.
Choice C reason: Encouraging ambulation is premature post-albuterol; patients need rest during exacerbation. It risks worsening dyspnea before confirming treatment success, making it less urgent than evaluating lung response to the bronchodilator.
Choice D reason: Documentation is essential but secondary to patient assessment post-treatment. Auscultating lung sounds first ensures albuterol’s effect is evaluated, as clinical response guides care before recording in the record.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Speech therapists assess swallowing in tracheostomy patients, as the tube alters airway dynamics. Collaboration ensures safe oral intake, preventing aspiration, a critical task aligning with their expertise in dysphagia management.
Choice B reason: Physical therapists plan mobility in tracheostomy care, enhancing strength and preventing atrophy. Collaboration promotes early activity, improving respiratory muscle function and recovery, tailored to the patient’s physical capacity.
Choice C reason: Respiratory therapists provide tracheostomy care, like suctioning and cuff management, maintaining airway patency. Collaboration ensures proper technique, reducing infection or obstruction risks, a core responsibility in respiratory support.
Choice D reason: Dietitians recommend nutrition plans for tracheostomy patients, addressing caloric and swallowing needs. Collaboration optimizes healing and energy, adjusting diets (e.g., thickened liquids) to support recovery and prevent complications.
Correct Answer is C
Explanation
Choice A reason: Ceftriaxone treats infection, but giving it before cultures risks sterilizing samples, skewing results. It’s critical therapy, yet obtaining accurate diagnostics first ensures targeted treatment, delaying antibiotics briefly.
Choice B reason: Antipyretics reduce fever, a symptom, not the cause. Cultures take priority to identify pathogens before comfort measures, as fever management doesn’t alter diagnostic or treatment urgency in this case.
Choice C reason: Blood and sputum cultures identify the causative organism in suspected infection (e.g., pneumonia). They must be obtained first, before antibiotics, to ensure accuracy, guiding effective therapy and avoiding false negatives.
Choice D reason: Monitoring glucose is routine, not urgent in acute infection unless diabetic crisis is suspected. Cultures precede this, as identifying the pathogen drives treatment, while glucose can wait without immediate risk.
Choice E reason: Monitoring intake and output tracks fluid status, useful but secondary in acute infection. Cultures are the priority to diagnose and treat effectively, as I&O doesn’t alter initial management decisions.
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