NURS 1500 Week 4

The nurse is caring for a client suspected of status asthmaticus. What is the priority nursing intervention?

• Notify the healthcare provider

• Prepare for endotracheal intubation

• Position the client in a semi-fowlers position

• Administer supplemental oxygen

Answer explanation

Iggy, p. 541

Rationale: Each of these interventions are beneficial, however, the client requires immediate intervention. Administering oxygen is the priority.

A 10-year-old with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition.

• Warm, dry skin

• Decreased wheezing

• Pulse rate of 90 beats/minute

• Respirations of 18 breaths/minute

Answer explanation

Iggy page 541

Rationale: Sudden absence of wheezing along with a low oxygen saturation indicates complete airway obstruction and requires a tracheotomy.

The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms would the nurse expect to find?

• Fever and crepitus

• Rales and hives

• Dyspnea and wheezing

• Normal chest shape and relaxed breathing

Answer explanation

Pg 535

Rationale: Symptoms of asthma exacerbation include: audible wheeze, increased respiratory rate, dyspnea, possible cough

A nurse is planning to teach one client pursed-lip breathing and another client diaphragmatic breathing. Which technique associated with diaphragmatic breathing is different from purse-lip breathing that the nurse should include in the teaching plan?

• Inhale through the nose

• Exhale through pursed lips

• Raise both shoulders while breathing deeply

• Tighten the abdominal muscles while exhaling

Answer explanation

Iggy Page 548

Inhalation through the nose for both diaphragmatic and pursed-lips breathing. Exhalation through pursed lip is performed only with pursed lip breathing. Raising both shoulders while breathing deeply is not part of diaphragmatic or pursed lip breathing. The use of accessory muscles of respiration is a compensatory mechanism that helps to increase thoracic excursion when inhaling. With diaphragmatic breathing, the contraction of abdominal muscles at the end of expiration helps to reduce the amount of air left in the lungs (residual volume).

A nurse evaluates that the client understood teaching about the purpose of pursed lip breathing when the client includes which information when explaining its purpose to a relative.

• Precipitates coughing

• Helps maintain open airway

• Decreases intrathoracic pressure

• Facilitates expectoration of mucus

Answer explanation

Deep breathing and huff coughing, not pursed lip breathing stimulates effective coughing. Pursed lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs, which prolongs exhalation and maintains positive airway pressure, thereby maintaining an open airway and preventing airway collapse. Pursed lip breathing increases, not decreases, intrathoracic pressure. The huff cough stimulates the natural cough reflex and is effective for clearing the central airways of sputum. Saying the word huff with short, forceful exhalations keeps the glottis open, mobilizes sputum, and stimulates a cough.

An infant is being admitted with RSV. The nurse knows to prepare for what type of isolation?

• Airborne Isolation

• Contact Isolation

• Droplet Isolation

• Standard Precautions

Answer explanation

Droplet precautions are used