Which of the following assessment findings would indicate that the nurse needs to take immediate action when caring for a client with asthma?
1. Tachycardia, tachypnea, and prolonged expirations
2. Diffuse wheezing and the use of accessory muscles when inhaling
3. Retractions, fatigue, and anxiety
4. Inaudible breath sounds, reduced wheezing, and an ineffective cough
4. Inaudible breath sounds, reduced wheezing, and an ineffective cough
Rationale:
Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that little or no air movement into and out of the lungs is taking place. Therefore, this set of symptoms represents the most urgent need, which is immediate intervention by the nurse to open up the lungs with drug management to prevent total respiratory failure. During an asthma attack, tachycardia, tachypnea, and prolonged expirations are common. They are early symptoms of the disease process and can be addressed without urgency. Diffuse wheezing and the use of accessory muscles when inhaling indicate a progression of the severity of the symptoms, but airflow is still occurring; therefore, they do not require the most urgent action. Retractions, fatigue, and anxiety are also a progression of symptoms that occur with an asthma attack and represent a more severe episode. But they are not the worst or most serious set of symptoms listed, because air is still moving and exchanging.
You might also like to view...
The best response for the nurse who receives a query from another mental health professional
seeking to understand the difference between a DSM-IV-TR diagnosis and a nursing diagnosis would be a. "There is no functional difference between the two; both serve to identify a human deviance.". b. "The DSM-IV-TR diagnosis disregards culture, whereas the nursing diagnosis takes culture into account.". c. "The DSM-IV-TR diagnosis is associated with present distress or disability, whereas a nursing diagnosis considers past and present responses to actual mental health problems.". d. "The DSM-IV-TR diagnosis affects the choice of medical treatment, whereas the nursing diagnosis offers a framework for identifying interventions for phenomena a client is experiencing.".
Which of the following studies would not be considered nursing research?
a. Assessing the knowledge base of caregivers of Alzheimer's patients b. Developing innovative pin insertion techniques for fracture treatment c. Evaluating the effectiveness of wound care in diabetic patients d. Reviewing staff nurse retention policies in rural hospital settings
The nurse is caring for a patient with gastroesophageal reflux disease (GERD). What should the nurse include when teaching the patient about this health problem?
Select all that apply. 1. Limit last food intake to 3 hours before bedtime. 2. Eat the largest meal of the day at midday. 3. Sleep in a bed with the head elevated 6 to 8 inches. 4. Follow a daily exercise routine. 5. Drink coffee with meals.
Complete the following ECG criteria for atrial tachycardia:
Rhythm __________________________ Rate __________________________ P waves __________________________ PR interval __________________________ QRS duration __________________________ Fill in the blanks with correct word