The nurse is caring for a patient newly diagnosed with asthma. Which assessment data indicates the need for an immediate intervention?
Bradypnea.
Decreased respiratory rate
Increased crackles
Diminished breath sounds
The Correct Answer is D
A. Bradypnea, or a slow respiratory rate, is concerning but not typically associated with asthma exacerbations. In asthma, patients usually experience tachypnea (increased respiratory rate) as they try to compensate for difficulty breathing.
B. A decreased respiratory rate in an asthma patient can be alarming, but it may not necessarily indicate an immediate need for intervention unless it’s associated with other severe symptoms. In general, asthma patients often have an increased respiratory rate due to respiratory distress.
C. While crackles can indicate fluid in the lungs and may suggest an underlying issue, they are not the most immediate concern in a patient with asthma. Crackles can occur in various conditions, and they alone may not necessitate urgent intervention.
D. Diminished breath sounds are a critical finding in asthma patients. This may indicate severe airway obstruction or a lack of air movement due to severe bronchospasm. In the context of asthma, diminished breath sounds can signify that the patient is not able to move air effectively, which requires immediate intervention to prevent respiratory failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While monitoring the child’s temperature is important for assessing fever and overall condition, it does not directly prevent the transmission of streptococcal infection. This response does not address methods to prevent spreading the illness to others.
B. Giving Tylenol (acetaminophen) can help relieve pain and reduce fever, which is important for the child’s comfort. However, this response does not address disease transmission prevention. It’s more about symptom management rather than infection control.
C. Discarding the toothbrush is a key infection control measure. Since the toothbrush can harbor bacteria from the throat, it’s essential to replace it after the child has been treated for streptococcal pharyngitis to prevent re-infection and reduce the risk of spreading the bacteria to others.
D. While encouraging fluid intake is important for recovery and can help soothe a sore throat, this response does not specifically address the prevention of disease transmission. It focuses more on the child’s care rather than controlling the spread of infection.
Correct Answer is B
Explanation
A. Long-acting beta2-adrenergic agonists (LABAs) are used for the maintenance treatment of asthma but are not suitable for immediate relief during an acute exacerbation. They take longer to take effect and are used as part of a long-term management plan rather than a rescue plan.
B. Short-acting beta2-adrenergic agonists (SABAs), such as albuterol, are the first-line treatment for acute asthma exacerbations. They work quickly to relax the muscles around the airways, providing immediate relief of bronchospasm and improving airflow. This is why they are referred to as "rescue" medications.
C. Mucolytics are used to thin and loosen mucus in the airways, which can be helpful for conditions involving thick mucus. However, they are not used for immediate relief of asthma symptoms and do not address bronchospasm directly. They are not appropriate as a first-line treatment in an acute asthma attack.
D. Inhaled corticosteroids are used for long-term control of asthma by reducing inflammation in the airways. While they are important for ongoing management, they do not provide immediate relief during an acute asthma exacerbation and should not be used as rescue medication.
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