Nokea
A client with asthma presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (SATA)
- A. Administer prescribed salmeterol (Serevent) inhaler.
- B. Assess the client for a tracheal deviation.
- C. Administer oxygen to maintain saturations above 94%.
- D. Perform peak expiratory flow measurements.
Correct Answer: C
Rationale: The correct answer is C. Administer oxygen to maintain saturations above 94%. In asthma exacerbation, maintaining oxygen saturation is crucial to prevent hypoxia. Oxygen therapy helps improve oxygen delivery to tissues and organs. Administering salmeterol (choice A) may help with long-term management but is not an immediate priority. Tracheal deviation assessment (choice B) is not relevant to asthma exacerbation. Performing peak expiratory flow measurements (choice D) may be helpful for monitoring asthma severity but is not the priority in this acute situation.
You may also like to solve these questions
A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?
- A. Administer albuterol treatment.
- B. Notify Rapid Response Team.
- C. Assess the client's peripheral pulses.
- D. Obtain blood and sputum cultures.
Correct Answer: B
Rationale: The correct answer is B: Notify Rapid Response Team. Continuous cyanosis despite oxygen therapy after benzocaine spray indicates possible methemoglobinemia, a life-threatening condition. Rapid Response Team can provide immediate intervention and transfer to a higher level of care. Administering albuterol (A) is not indicated for methemoglobinemia. Assessing peripheral pulses (C) may not address the underlying issue. Obtaining blood and sputum cultures (D) is not the priority in this acute situation.
The disease progress of cancers, such as cervical or Hodgkin’s, can be classified according to a clinical staging system. Place the description of stages 0-IV in the correct order.
- A. Metastasis.
- B. Limited local spread.
- C. Cancer in situ.
- D. Tumor limited to tissue of origin.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nursing student is providing tracheostomy care. What action by the student requires intervention by the instructor?
- A. Holding the device securely when changing ties
- B. Suctioning the client first if secretions are present
- C. Tying a square knot at the back of the neck
- D. Using half-strength peroxide for cleansing
Correct Answer: C
Rationale: The correct answer is C: Tying a square knot at the back of the neck. The reason this action requires intervention is that a square knot is not recommended for securing tracheostomy ties as it can be difficult to untie in an emergency. Instead, a quick-release knot or Velcro closure is typically used for easy removal.
A: Holding the device securely when changing ties is important for maintaining the integrity of the tracheostomy.
B: Suctioning the client first if secretions are present is a standard practice to ensure clear airways.
D: Using half-strength peroxide for cleansing is appropriate for tracheostomy care to prevent infection.
In summary, the incorrect choice is C because tying a square knot can pose risks in an emergency situation, while the other choices are appropriate actions in tracheostomy care.
A client with asthma is being taught about peak flow meter use. Which statement by the client indicates understanding of the teaching?
- A. I will use my peak flow meter every morning.
- B. I will use my peak flow meter when I feel short of breath.
- C. I will use my peak flow meter before using my inhaler.
- D. I will use my peak flow meter after using my inhaler.
Correct Answer: A
Rationale: The correct answer is A because using the peak flow meter every morning provides a baseline measurement of lung function when the client is typically stable. This allows for early detection of changes and adjustment of treatment. Choice B is incorrect as waiting until feeling short of breath may be too late. Choice C is incorrect because using the peak flow meter before the inhaler may not provide an accurate measurement. Choice D is incorrect as using the peak flow meter after the inhaler may not reflect the true lung function.
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?
- A. Elevate the head of the client's bed.
- B. Measure and compare cuff pressures.
- C. Place the client on NPO status.
- D. Request a swallow study for the client.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Tracheostomy cuff should be inflated to prevent aspiration.
2. Food particles indicate cuff leakage.
3. Measuring cuff pressure ensures proper sealing.
4. Prevents aspiration and respiratory complications.
Summary:
A: Elevating the head is beneficial but doesn't address cuff leakage.
C: NPO status is extreme and unnecessary without confirmation of aspiration risk.
D: Swallow study is for assessing swallowing function, not related to cuff pressure.