a client with asthma is experiencing a severe exacerbation what is the nurses priority
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Nursing Elites

HESI LPN

Adult Health 1 Final Exam

1. During a severe asthma exacerbation in a client, what is the nurse's priority?

Correct answer: A

Rationale: During a severe asthma exacerbation, the nurse's priority is to administer a rescue inhaler immediately. This action helps open the airways and improve breathing, which is crucial in managing the exacerbation. Choice B, preparing for intubation, would be considered if the client's condition deteriorates and they are unable to maintain adequate oxygenation even after using the rescue inhaler. Encouraging deep breathing exercises (Choice C) may not be appropriate during a severe exacerbation as the client may struggle to breathe. While monitoring oxygen saturation levels (Choice D) is important, the immediate administration of a rescue inhaler takes precedence to address the acute breathing difficulty.

2. A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the nurse provide?

Correct answer: D

Rationale: The correct answer is D because informing about state law emphasizes the legal requirement and public health rationale behind prophylactic eye treatment to prevent serious infections like gonorrheal or chlamydial ophthalmic infection. Choices A, B, and C are incorrect. Choice A focuses on staphylococcus infection, which is not the primary concern addressed by the prophylactic ointment. Choice B mentions a specific infection acquired from the mother's infected vagina, which is not the main reason for the ophthalmic ointment. Choice C discusses tear duct obstruction and dry eyes, which are not the primary concerns addressed by the prophylactic ointment.

3. The nurse is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedule physical exercises with the physical therapy department?

Correct answer: B

Rationale: Scheduling physical exercises after breakfast is the optimal choice for a client with Myasthenia Gravis. This timing allows the client to benefit from renewed energy levels after overnight rest and intake of morning nourishment, enhancing the effectiveness of the therapy session. Choices A (Before bedtime, at 2000) is not suitable as energy levels are likely lower at night, affecting the client's ability to engage effectively in physical exercises. Choices C (Before the evening meal) and D (After lunch) may not be ideal as the client may experience fatigue or weakness later in the day, making it harder to participate actively in therapy.

4. A healthcare provider is reviewing a client's medication list during a routine visit. Which action is most important to ensure medication safety?

Correct answer: D

Rationale: A comprehensive review of allergies, medication purposes, and potential interactions is crucial for ensuring medication safety. Asking about allergies helps prevent adverse reactions, reviewing medication purposes ensures the correct use of each drug, and checking for potential drug interactions reduces the risk of harmful effects when medications interact. Choosing 'All of the above' is the correct answer because all three actions are essential steps to enhance medication safety. Options A, B, and C individually play vital roles in promoting medication safety, making option D the most appropriate choice.

5. A client is receiving morphine for pain management. What is the most important assessment for the nurse to perform?

Correct answer: A

Rationale: The correct answer is to check the client's respiratory rate. Morphine can lead to respiratory depression, which makes it crucial for the nurse to monitor the client's breathing closely. Assessing the respiratory rate helps in early detection of potential respiratory depression and allows prompt intervention. While assessing pain level (choice B) is important, monitoring the respiratory status takes precedence due to the risk of respiratory depression with morphine. Monitoring blood pressure (choice C) is relevant but not as crucial as assessing respiratory status in a client receiving morphine. Evaluating the level of consciousness (choice D) is also important but does not directly address the immediate risk associated with morphine administration.

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