Prioritizing Questions
While receiving an adrenergic beta2 agonist drug for asthma, the client complains of palpitations, chest pain, and a throbbing headache. What is the most appropriate nursing action? 1. Withhold the drug until additional orders obtained. 2. Tell the client not to worry; these are expected s/e from the medicine. 3. Ask the client to relax, then give instructions to breathe slowly and deeply for several minutes. 4. Explain that the effects are temporary and will subside as the body becomes accustomed to the drug.
Answer 1 1. These drugs cause increased heart contraction (positive inotropic effect) and increased heart rate (positive chronotropic effect). If toxic levels are are reached, s/e occur and the drug should be withheld until the health care provider is notified. 2. This is false reassurance and a false statement. 3, 4 Controlled breathing may be helpful in allying a client's anxiety; however, the drug may be producing adverse effects and should be withheld.
A nurse is caring for a variety of clients. For which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? 1. 59-year-old who had a knee replacement 2. 60-year-old who has bacterial pneumonia 3. 68-year-old who had emergency dental surgery 4. 76-year-old who has a hx of thrombocytopenia
Answer is 1 1. clients who have had joint replacement have decreased mobility; the y are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodge into the circulation. 2, 3. This in not associated with an increased risk for pulmonary embolism. 4. This leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.
A client is admitted for an exacerbation of emphysema. The client has a fever, chills and difficulty breathing on exertion. What is the priority nursing action based on the client's history and present status? 1. Checking for capillary refill 2. Encouraging increased fluid intake 3. Suctioning secretions from the airway. 4. Administering a high concentration of oxygen.
Answer is 2 2. Fluids will replace fluid loss from fever and decreased viscosity of secretions 1. Capillary refill relates to peripheral tissue perfusion. 3. There are no data to suggest that secretions are blocking the airway; there is no support that suctioning is needed. 4. High concentration of oxygen generally are not administered to clients wit COPD.
What is the priority goal for a client wit asthma who is being discharged from the hospital? 1. Is able to obtain pulse oximeter readings. 2. Demonstrates use of a metered-dose inhaler. 3. Knows the health care provider's office hours. 4. Can identify the foods that may cause wheezing.
Answer is 2 2. clients with asthma use metered-dose inhalers to administer medications prophylactically and/or during times of an asthma attack; this is an important skill to have before discharge. 1. Pulse oximetry is rarely conducted in the home; home management usually includes self-monitoring of the peak expiratory flow rate. 3. Although this is important, it is not the priority; during a persistent asthma attack that does not respond to planned interventions the client should go to the emergency department of the local hospital or call 911 for assistance. 4. Not all asthma is associated with food allergies.
A medical-surgical unit nurse has just received the nursing shift report and is preparing to make rounds. Which client should the nurse see first? 1. The client being prepared for discharge after a femoral popliteal bypass graft 2. The client with a cerebral aneurysm with a O2 sat of 99% 3. The cleint three days after a coronary artery bypass surgery with a fever of 100.2 degrees. 4. The client admitted an hour ago with difficulty of breathing.
Correct answer is 4 Rationale: The client who has just been admitted with difficulty of breathing should be seen first and needs further evaluation. The other clients are in non-emergent situation and it is expected to have a slight fever after a major operation.
