You are an RN in a busy Emergency Department who is caring for a patient who was brought in for an acute asthma attack about 5 minutes ago. Upon arrival, the patient was loudly wheezing and able to talk in 4 to 5 word sentences. A couple of minutes later as you are charting, you notice that you can no longer hear the patient wheezing. You know you should now.
Reassess the client for a potential life-threatening development
Prepare the client for discharge
Chart that the patient has improved on their own
Return the Albuterol to medication bin as you will no longer need it
The Correct Answer is A
A. The absence of wheezing in a patient with an acute asthma attack is a critical sign. It may indicate that the patient is deteriorating rapidly, and their airways are closing significantly. This is a life-threatening situation requiring immediate intervention.
B. A patient with an acute asthma attack would not be discharged without significant improvement and stabilization.
C. While it might seem like an improvement, the absence of wheezing in this context is a red flag and not a positive sign.
D. The patient may still require additional bronchodilators or other interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. As the heart's ability to pump blood is compromised, blood pressure decreases.
B. Bounding pulses are associated with increased cardiac output, which is opposite to what occurs in cardiac tamponade.
C. Beck's Triad: This classic triad includes hypotension, muffled heart sounds, and jugular venous distention, all indicative of cardiac tamponade.
D. Muffled heart sounds are a characteristic of cardiac tamponade due to the fluid accumulation around the heart.
E. Jugular veins are distended: The increased pressure in the right atrium due to impaired ventricular filling leads to distended jugular veins.
Correct Answer is C
Explanation
A. While oral glucose is a good option for mild hypoglycemia, this patient is severely hypoglycemic and unable to swallow.
B. This is also appropriate for mild hypoglycemia, but the patient's condition warrants a more rapid- acting intervention.
C. D50 is a concentrated glucose solution that is administered intravenously for rapid correction of severe hypoglycemia. Given the patient's lethargic state and inability to follow commands, IV glucose is the most appropriate and immediate intervention.
D. While glucagon is an effective treatment for hypoglycemia, it is not the first-line treatment for a patient who is able to receive IV glucose. IV glucose is faster-acting and more reliable in this situation.
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