While assessing a client with status asthmaticus, the nurse notes diminished breath sounds in all lung fields and the client is becoming confused. The nurse should prepare the client for:
Pulmonary function testing.
Mechanical ventilation.
Chest x-ray.
2 liters of oxygen via nasal cannula.
The Correct Answer is B
Choice A reason:
Pulmonary function testing is not the immediate priority for a client with status asthmaticus who is showing signs of respiratory failure, such as diminished breath sounds and confusion. Pulmonary function tests are useful for diagnosing and assessing the severity of asthma but are not appropriate during an acute, life-threatening exacerbation.
Choice B reason:
Mechanical ventilation is the correct intervention for a client with status asthmaticus who is exhibiting signs of respiratory failure. Diminished breath sounds and confusion indicate severe airway obstruction and hypoxia, necessitating immediate intervention to secure the airway and ensure adequate ventilation. Mechanical ventilation helps to maintain oxygenation and ventilation until the underlying cause can be treated.
Choice C reason:
A chest x-ray can be useful in diagnosing complications such as pneumothorax or pneumonia in a client with status asthmaticus, but it is not the immediate priority when the client is showing signs of respiratory failure. The primary focus should be on stabilizing the client’s respiratory status.
Choice D reason:
Administering 2 liters of oxygen via nasal cannula is not sufficient for a client with severe status asthmaticus and signs of respiratory failure. High-flow oxygen delivery methods or mechanical ventilation are required to adequately support the client’s respiratory needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Reducing rebreathing of exhaled air is not a primary characteristic of a Venturi mask. This feature is more associated with non-rebreather masks, which have a one-way valve to prevent exhaled air from being inhaled again.
Choice B reason:
Delivering high percentages of oxygen at flow rates of 10 to 15 L/min is not specific to Venturi masks. Non-rebreather masks are typically used for high oxygen flow rates. Venturi masks are designed to deliver precise oxygen concentrations at lower flow rates.
Choice C reason:
Providing a precise amount of oxygen is the key characteristic of a Venturi mask. Venturi masks are equipped with color-coded adapters that allow for the delivery of specific oxygen concentrations, regardless of the patient’s breathing pattern.
Choice D reason:
Working independently of client breathing factors and flow of oxygen is not entirely accurate. While Venturi masks do provide a consistent oxygen concentration, they still depend on the flow of oxygen set by the healthcare provider.
Correct Answer is A
Explanation
Choice A reason: Fine crackles are often associated with bronchitis, particularly chronic bronchitis. These sounds are caused by the presence of mucus in the airways, which creates a crackling noise when air passes through. Chronic bronchitis involves inflammation and increased mucus production in the bronchi, leading to these characteristic lung sounds.
Choice B reason: A pneumothorax, or collapsed lung, typically presents with absent or diminished breath sounds on the affected side rather than fine crackles. The absence of breath sounds is due to the lack of air movement in the collapsed portion of the lung. Fine crackles are not a common finding in pneumothorax.
Choice C reason: Asthma is characterized by wheezing, which is a high-pitched whistling sound caused by narrowed airways. While crackles can occasionally be heard in asthma, they are not the primary lung sound associated with this condition. Wheezing is more indicative of asthma due to bronchoconstriction and inflammation.
Choice D reason: Emphysema, a form of chronic obstructive pulmonary disease (COPD), typically presents with decreased breath sounds and prolonged expiration rather than fine crackles. The destruction of alveolar walls in emphysema leads to reduced lung sounds overall. Fine crackles are not a hallmark of emphysema.
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