While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bedside table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed lip breathing. Which intervention should the nurse implement?

Increase oxygen to 6 liters/minute.

Call for an Ambu resuscitation bag.

Instruct the client to lie back in bed.

Administer a nebulizer treatment.

Answer and Explanation

The Correct Answer is D

Choice A: Increasing oxygen to 6 liters/minute is not an intervention that the nurse should implement, as this can worsen bronchospasm and hypoxia by reducing the hypoxic drive and causing carbon dioxide retention. This is a contraindicated choice.

Choice B: Calling for an Ambu resuscitation bag is not an intervention that the nurse should implement, as this is not indicated for a client who is conscious and breathing spontaneously. This is an overreaction choice.

Choice C: Instructing the client to lie back in bed is not an intervention that the nurse should implement, as this can increase respiratory distress and compromise airway clearance by reducing lung expansion and increasing abdominal pressure. This is another contraindicated choice.

Choice D: Administering a nebulizer treatment is an intervention that the nurse should implement, as this can deliver bronchodilators and anti-inflammatory agents directly to the airways and improve ventilation and oxygenation for this client. Therefore, this is the correct choice.

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Correct Answer is C

Explanation

Choice A reason: Providing pain medication to increase the client's tolerance of labor pains is not a specific intervention for the second stage of labor. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Pain medication can be given during any stage of labor, depending on the client's preference and condition. However, pain medication may have side effects such as sedation, nausea, or respiratory depression, and may affect the fetal heart rate or the progress of labor.

Choice B reason: Assessing the fetal heart rate and pattern for signs of fetal distress is not a particular intervention for the second stage of labor. Fetal heart rate and pattern are indicators of fetal well-being and oxygenation. Fetal heart rate and pattern should be monitored throughout labor, especially during contractions, to detect any abnormalities or complications such as bradycardia, tachycardia, or decelerations.

Choice D reason: Monitoring effects of oxytocin administration to help achieve cervical dilation is not a relevant intervention for the second stage of labor. Oxytocin is a hormone that stimulates uterine contractions and cervical dilation. Oxytocin can be administered during labor to augment or induce labor, especially if there is prolonged or dysfunctional labor. However, oxytocin is not needed in the second stage of labor, when the cervix is already fully dilated and the focus is on pushing and delivering the baby.

A. Serum potassium, calcium, and phosphorus B. Erythrocytes, hemoglobin, and hematocrit C. Leukocytes, neutrophils, and thyroxine D. Blood pressure, heart rate, and temperature

Correct Answer is A

Explanation

Choice B reason: Erythrocytes, hemoglobin, and hematocrit are laboratory results that are not as critical as serum potassium, calcium, and phosphorus in a client who has end-stage renal disease (ESRD.. Erythrocytes are red blood cells that carry oxygen from the lungs to the tissues. Hemoglobin is a protein in erythrocytes that binds oxygen. Hematocrit is the percentage of blood volume that is occupied by erythrocytes. ESRD can cause anemia (low erythrocyte, hemoglobin, and hematocrit levels) due to reduced production of erythropoietin, a hormone that stimulates erythrocyte formation, by the kidneys. Anemia can cause fatigue, pallor, or shortness of breath.

Choice C reason: Leukocytes, neutrophils, and thyroxine are laboratory results that are not as relevant as serum potassium, calcium, and phosphorus in a client who has end-stage renal disease (ESRD.. Leukocytes are white blood cells that fight infection and inflammation. Neutrophils are a type of leukocyte that respond to bacterial infection. Thyroxine is a hormone that regulates metabolism and growth. ESRD can cause leukopenia (low leukocyte levels) and neutropenia (low neutrophil levels) due to impaired immune function and increased susceptibility to infection. ESRD can also cause hypothyroidism (low thyroxine levels) due to reduced clearance of thyroid hormones by the kidneys. Hypothyroidism can cause weight gain, cold intolerance, or depression.

Choice D reason: Blood pressure, heart rate, and temperature are not laboratory results, but vital signs that should be monitored in a client who has end-stage renal disease (ESRD.. Blood pressure is the force of blood against the walls of the arteries. Heart rate is the number of times the heart beats per minute. Temperature is the measure of body heat. ESRD can cause hypertension (high blood pressurE. due to fluid overload and activation of the renin-angiotensin-aldosterone system, a hormonal pathway that regulates blood pressure and fluid balance. Hypertension can cause headache, chest pain, or stroke. ESRD can also cause tachycardia (high heart ratE. due to anemia, fluid overload, or electrolyte imbalance. Tachycardia can cause palpitations, dizziness, or heart failure. ESRD can also cause fever (high temperaturE. due to infection or inflammation. Fever can cause chills, sweating, or delirium.

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Naxlex Comprehensive Predictor Exams

What nursing intervention is particularly indicated for the second stage of labor?

Correct Answer is C

Explanation

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD.?

Correct Answer is A

Explanation

When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take?

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donninggloves and a gown to assist the client. Which action should the nurse take?

An adolescent from a poor neighborhood who has a history of severe chronic obstructive pulmonary disease (COPD. and peripheral vascular disease (PVD. is being discharged from a funded nursing facility. Which action is most important for the nurse to implement?

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?