The nurse is providing care to a client admitted after experiencing an acute asthma attack. Which assessment findings indicate the need for immediate intervention by the nurse?

Question

Select all that apply.
A) Retractions and fatigue
B) Tachycardia and tachypnea
C) Inaudible breath sounds
D) Diffuse wheezing and the use of accessory muscles when inhaling
E) Reduced wheezing and an ineffective cough

Answer 1

Answer: C, E

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 and fatigue 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.