Hesi RN Medical Surg Related

Review Hesi RN Medical Surg related questions and content

History and Physical
Nurses' Notes
Orders
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.

After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

  • A. Administer additional nebulizer treatment as ordered.
  • B. Take and monitor vital signs.
  • C. Apply a nonrebreather oxygen mask.
  • D. Increase oxygen flow.
  • E. Raise the head of the bed.
  • F. Provide client incentive spirometer and instruct on use.
Correct Answer: A,B,D,E

Rationale: Additional nebulizer treatment targets persistent wheezing, monitoring vital signs tracks response, increasing oxygen flow addresses low saturation, and raising the bed aids breathing. A nonrebreather is unnecessary at this stage, and incentive spirometry (F) is not indicated during an acute attack.