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RN-Hesi Medical Surgical VII

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1 :
A Client in the Emergency Department

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.

Temperature 98.9" F (37.1" C).

Heart rate 112 beats/minute

Respirations 28 breaths/minute

Blood pressure 130/86 mm Hg.

Oxygen saturation 88% on room air

Lung sounds reveal expiratory wheezes

Capillary refill time 2 seconds

Administer albuterol 2.5 mg/ipratropium bromide 0.5 mg in 3 mL solution via nebulizer four times a day and PRN Administer prednisone 60 mg PO Administer oxygen to keep oxygen saturation greater than 94%, titrate as needed

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.

Answer Options

Administer additional nebulizer treatment as ordered.

Take and monitor vital signs.

Apply a nonrebreather oxygen mask.

Increase oxygen flow.

Raise the head of the bed.

Provide client incentive spirometer and instruct on use.

Hint : 🛏️ Repeat neb, reassess, reposition

Correct Answers:

Administer additional nebulizer treatment as ordered.
Take and monitor vital signs.
Raise the head of the bed.

Rationale :

🔷 Administer additional nebulizer treatment as ordered

🟡 The persistence of wheezing and shortness of breath indicates ongoing bronchospasm that requires further bronchodilation.

🟡 Albuterol and ipratropium combination therapy helps relax the smooth muscles of the airways and reduce mucus production.

🟡 Repeating the treatment is safe under PRN orders and is a standard protocol in acute asthma management.

🟡 This step addresses the underlying airflow obstruction and aims to restore adequate oxygenation.

🔷 Take and monitor vital signs

🟡 Continuous monitoring helps assess the effectiveness of interventions and provides early detection of deterioration.

🟡 Respiratory rate, heart rate, and oxygen saturation trends can indicate either improvement or progression of respiratory distress.

🟡 Monitoring also helps detect side effects from beta-agonists such as tachycardia or arrhythmias.

🟡 Accurate and timely data supports appropriate escalation or de-escalation of care.

🔷Raise the head of the bed

🟡 Positioning the client in a High Fowler’s position enhances lung expansion by reducing abdominal pressure on the diaphragm.

🟡 This posture allows more effective breathing and facilitates oxygen exchange at the alveolar level.

🟡 It is a rapid, non-pharmacological intervention that improves patient comfort during respiratory distress.

🟡 Combining this with oxygen therapy can maximize oxygen delivery and ease work of breathing.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 : A Client in the Emergency Department

Answer Options

1 :
A Client in the Emergency Department