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During an acute exacerbation of asthma, what is the nurse's first action for a client experiencing this condition?
- A. Administer a bronchodilator as prescribed.
- B. Check the client's oxygen saturation.
- C. Reassure the client and encourage deep breathing.
- D. Provide emotional support to reduce anxiety.
Correct Answer: A
Rationale: The correct first action when managing an acute exacerbation of asthma is to administer a bronchodilator as prescribed. Bronchodilators help open the airways and improve breathing in individuals experiencing an asthma exacerbation. Checking oxygen saturation (Choice B) is important but not the first action. Reassuring the client and encouraging deep breathing (Choice C) can be beneficial but should come after administering the bronchodilator. Providing emotional support to reduce anxiety (Choice D) is important but is not the initial priority in managing an acute exacerbation of asthma.
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A client with heart failure reports nausea, vomiting, yellow vision, and palpitations. What should the nurse assess first?
- A. Administer antiemetics to reduce nausea.
- B. Obtain a list of the client's cardiac medications.
- C. Perform an ECG to evaluate heart function.
- D. Review the client's dietary intake for possible causes.
Correct Answer: B
Rationale: The combination of nausea, vomiting, yellow vision, and palpitations in a heart failure patient is indicative of digoxin toxicity. The nurse should first obtain a list of the client's medications to verify if they are taking digoxin.
A client is receiving IV fluid therapy for dehydration. Which assessment finding indicates that the client's fluid status is improving?
- A. Urine output increases to 50 mL/hour
- B. Client reports feeling more thirsty
- C. Blood pressure decreases from 120/80 to 110/70
- D. Heart rate increases from 80 to 100 beats per minute
Correct Answer: A
Rationale: An increase in urine output is a positive sign that the client's hydration status is improving. It indicates that the kidneys are functioning well and that fluid therapy is effective. Increased urine output helps to eliminate excess fluid and waste products from the body. Choices B, C, and D are incorrect. Feeling more thirsty (choice B) is a sign of dehydration, not improvement. A decrease in blood pressure (choice C) and an increase in heart rate (choice D) are not typically indicative of improving fluid status during IV fluid therapy for dehydration.
A client with type 1 diabetes is admitted to the emergency room with abdominal pain, polyuria, and confusion. What should the nurse implement first?
- A. Administer intravenous insulin.
- B. Start an intravenous fluid bolus.
- C. Obtain a blood glucose level.
- D. Administer an antiemetic.
Correct Answer: B
Rationale: In this scenario, the nurse should first start an intravenous fluid bolus. This intervention is crucial in addressing severe dehydration associated with diabetic ketoacidosis, a life-threatening complication of type 1 diabetes. Administering intravenous insulin (Choice A) is important but should follow fluid resuscitation. Obtaining a blood glucose level (Choice C) is necessary but not as urgent as addressing the dehydration. Administering an antiemetic (Choice D) is not the priority in this situation.
A client with pneumonia is receiving oxygen via nasal cannula at 2 L/min. What assessment finding indicates the need for further intervention?
- A. The client reports feeling short of breath.
- B. The client's oxygen saturation is 92%.
- C. The client's respiratory rate is 20 breaths per minute.
- D. The client is unable to complete sentences without pausing.
Correct Answer: D
Rationale: The correct answer is D because the inability to complete sentences without pausing indicates respiratory distress and the need for immediate intervention. This finding suggests an increased work of breathing and inadequate oxygenation. Choices A, B, and C are not as urgent as choice D. Feeling short of breath (choice A) is expected in pneumonia but does not necessarily indicate the need for immediate intervention. An oxygen saturation of 92% (choice B) is slightly below the normal range but may not require immediate intervention. A respiratory rate of 20 breaths per minute (choice C) is within the normal range and does not signify an urgent need for intervention.
During a neurologic assessment of a client with a suspected stroke, which finding is most concerning?
- A. Unilateral facial droop
- B. Slurred speech
- C. Weakness in one arm
- D. Sudden loss of consciousness
Correct Answer: D
Rationale: Sudden loss of consciousness in a client with a suspected stroke is the most concerning finding as it indicates a more severe neurological event, such as brain stem involvement or hemorrhage, requiring immediate intervention. While unilateral facial droop, slurred speech, and weakness in one arm are all common signs of a stroke, sudden loss of consciousness signifies a critical condition that needs urgent attention and evaluation to prevent further complications.