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 hospitalized toddler who is recovering from a sickle cell crisis holds a toy and says, 'Mine.' According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage?

Correct answer: A

Rationale: The toddler's behavior of asserting possession ('Mine') reflects a desire for independence, aligning with Erikson's stage of Autonomy vs. Shame and Doubt. This stage, typical for toddlers aged 1-3 years, focuses on developing a sense of control and independence. Choices B, C, and D are incorrect: Industry vs. Inferiority relates to middle childhood, Initiative vs. Guilt pertains to preschoolers, and Trust vs. Mistrust is associated with infancy.

3. The healthcare provider is providing discharge instructions to a client with chronic heart failure. Which dietary recommendation is most appropriate?

Correct answer: B

Rationale: The most appropriate dietary recommendation for a client with chronic heart failure is to follow a low-sodium diet. This helps manage the condition by reducing fluid retention and the workload on the heart. High fluid intake can lead to fluid overload and exacerbate heart failure symptoms. While protein is important for overall health, a high-protein diet is not specifically indicated for chronic heart failure. Increasing sodium intake is contraindicated in heart failure as it can worsen fluid retention and increase the workload on the heart.

4. A client with a diagnosis of tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?

Correct answer: B

Rationale: The most important instruction for a client with tuberculosis (TB) is to take all prescribed medications as directed. This is crucial to prevent the development of drug-resistant TB. While avoiding close contact with others until treatment is complete (Choice A) is important to prevent the spread of TB, ensuring the client completes the prescribed medication regimen is the priority. Scheduling a follow-up appointment (Choice C) is important for monitoring but not as critical as medication adherence. Wearing a mask in public places (Choice D) can help reduce the spread of TB but is not as essential as taking medications as prescribed.

5. The nurse is assessing a client with an IV infusion of normal saline. The client reports pain and swelling at the IV site. What should the nurse do first?

Correct answer: D

Rationale: The correct answer is to discontinue the IV infusion. Pain and swelling at the IV site may indicate infiltration or phlebitis, which requires immediate discontinuation of the infusion to prevent further complications. Continuing the infusion can lead to tissue damage or infection. Slowing the rate of infusion, applying a warm compress, or elevating the affected arm would not address the underlying issue of infiltration or phlebitis and could potentially worsen the condition by allowing more fluid to infiltrate the tissues.

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