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Which of the following actions should the nurse take immediately?
(Select the 4 actions the nurse should take.)

Exhibits

Administer oxygen

Obtain prescription for amiodarone

Place client in semiFowler's position

Monitor blood pressure every 30 minutes

Obtain prescription for a beta blocker

Monitor for neurologic complications

Answer and Explanation

Correct Answer : A,C,E,F

Rationale:

A. Administer oxygen: The client is experiencing labored respirations and increasing distress. Although their oxygen saturation is currently within normal range, supplemental oxygen is a priority to support oxygenation during this acute episode, especially with signs of anxiety and shortness of breath.

B. Obtain prescription for amiodarone: Amiodarone is used for certain ventricular arrhythmias. The client’s heart rhythm is described as regular, though tachycardic, not indicating a need for amiodarone. This is not an immediate priority without evidence of a specific arrhythmia like ventricular tachycardia.

C. Place client in semi-Fowler's position: Elevating the head of the bed helps reduce the work of breathing and improves lung expansion. This position supports respiratory function, especially when the client is experiencing shortness of breath.

D. Monitor blood pressure every 30 minutes: Blood pressure monitoring is important, but this action is not immediate in the face of worsening symptoms. The client needs more urgent interventions first, including respiratory and cardiac stabilization.

E. Obtain prescription for a beta blocker: The client’s heart rate increased significantly to 170/min and they have a history of poorly controlled hypertension. A beta blocker may be needed to reduce sympathetic overactivity and heart rate, helping to lower blood pressure and myocardial oxygen demand.

F. Monitor for neurologic complications: With a blood pressure of 185/100 mmHg and a worsening severe headache, the client is at risk for neurologic complications such as hypertensive encephalopathy or stroke. Close neurologic monitoring is essential to detect early signs of deterioration.

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Correct Answer is A

Explanation

Rationale:
A. Increased thirst: Polydipsia, or excessive thirst, is a classic symptom of hyperglycemia. It results from the body's attempt to counteract dehydration caused by osmotic diuresis, which occurs when high glucose levels pull fluid into the urine.

B. Decreased urine output: Hyperglycemia typically causes polyuria (increased urine output), not decreased. High glucose concentrations in the blood lead to osmotic diuresis, resulting in frequent and excessive urination.

C. Moist skin: Hyperglycemia is more often associated with dry skin and mucous membranes due to fluid loss. Moist, clammy skin is more characteristic of hypoglycemia, particularly when it is accompanied by sweating and other adrenergic symptoms.

D. Tremors: Tremors are more commonly associated with hypoglycemia due to increased sympathetic nervous system activity. Hyperglycemia usually develops more gradually and does not typically produce tremors.

A. Coughing B. Flat neck veins C. Use of accessory muscles D. Presence of coarse crackles

Correct Answer is C

Explanation

Rationale:
A. Coughing: While coughing is a common symptom of asthma, it is not specific to status asthmaticus. It can occur during mild, moderate, or severe asthma episodes and does not necessarily indicate life-threatening severity.

B. Flat neck veins: Flat neck veins are not characteristic of status asthmaticus. In severe respiratory distress, the client may show signs of increased intrathoracic pressure, which can lead to distended neck veins rather than flat ones.

C. Use of accessory muscles: The use of accessory muscles to breathe is a sign of severe respiratory distress and indicates that the client is struggling to maintain adequate ventilation. This is a hallmark of status asthmaticus, a life-threatening condition requiring immediate intervention.

D. Presence of coarse crackles: Coarse crackles are more commonly associated with fluid in the lungs, such as in pneumonia or heart failure. In status asthmaticus, breath sounds may be diminished or absent due to severe airway obstruction, rather than producing crackles.

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(Select the 4 actions the nurse should take.)

Exhibits