The nurse plans care for the client who has asthma and receives albuterol nebulizer therapy. The client's respiratory rate is 34 breaths per minute and breath sounds reveal wheezing throughout both lung fields
Which outcome is the nurse's priority for this client within 24 hours? 1. Client self-administers medication using the nebulizer.
2. Client correctly describes use of small-volume nebulizer.
3. Client recites side effects and clinical indicators to report.
4. Client's respiratory rate falls below 28 breaths per minute.
4
4. Airway and breathing are usually at the top of client priorities, so the nurse works to improve the client's respiratory status first. The nurse's priority for the client is to gain control of the respiratory system before the client goes into respiratory failure; thus, the nurse focuses on decreasing the respiratory rate because the client cannot sustain the tachypnea for long without becoming exhausted. By reducing or elimi-nating wheezing, the client's airways dilate, more air moves in and out through wi-dened airways, oxygen tension and ventilation increase, the work of breathing de-creases, and the respiratory rate falls as the client's oxygenation improves.
1. Self-administration is contraindicated for the client during an acute episode.
2 and 3. Describing the use of a nebulizer and verbalizing information is indicated before discharge and not during an acute episode.
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