which of the following is a primary nursing intervention for a patient experiencing an acute asthma attack
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Evolve HESI Medical Surgical Practice Exam Quizlet

1. What is the primary nursing intervention for a patient experiencing an acute asthma attack?

Correct answer: A

Rationale: The correct answer is administering bronchodilators. During an acute asthma attack, the primary goal is to relieve airway constriction and bronchospasm to improve breathing. Bronchodilators, such as short-acting beta-agonists, are the cornerstone of treatment as they help dilate the airways quickly. Administering antibiotics (choice B) is not indicated unless there is an underlying bacterial infection. Administering IV fluids (choice C) may be necessary in some cases, but it is not the primary intervention for an acute asthma attack. Administering corticosteroids (choice D) is often used as an adjunct therapy to reduce airway inflammation, but it is not the primary intervention during the acute phase of an asthma attack.

2. What is the most important nursing intervention for a patient with increased intracranial pressure (ICP)?

Correct answer: A

Rationale: Elevating the head of the bed to 30 degrees is crucial for a patient with increased intracranial pressure (ICP) because it helps promote venous drainage from the brain, thereby reducing ICP. Keeping the head of the bed elevated helps facilitate cerebral perfusion and can prevent a further increase in ICP. Administering diuretics (Choice B) may be considered in some cases to reduce fluid volume, but it is not the most critical intervention for immediate ICP management. Administering corticosteroids (Choice C) is not typically indicated for managing increased ICP unless there is a specific underlying condition requiring their use. Keeping the patient in a supine position (Choice D) can actually worsen ICP by impeding venous outflow from the brain, making it an incorrect choice for this scenario.

3. A healthcare professional reviews a client’s laboratory results. Which results from the client’s urinalysis should the healthcare professional identify as normal? (Select all that apply.)

Correct answer: D

Rationale: In a urinalysis, a pH of 6 is within the normal range (typically between 4.6 and 8); a specific gravity of 1.015 is considered normal (usually ranging between 1.005 to 1.030); and a negative glucose result is also normal. Therefore, choices A, B, and C are correct as they fall within the normal values for a urinalysis. Choices A, B, and C are the correct answers, as the pH, specific gravity, and glucose levels are within the normal range for a urinalysis. Choice D is correct because all the listed values are normal. Choices A, B, and C are the correct options as they meet the criteria for normal urinalysis values. The other choices do not fall within the normal range for a urinalysis.

4. A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return?

Correct answer: B

Rationale: In clients with heart failure, placing them in high Fowler's position is beneficial as it helps reduce venous return and improve ventilation. This position aids in decreasing the workload on the heart by promoting better lung expansion and oxygenation. Passive range of motion exercises (Choice A) are not directly related to improving ventilation or reducing venous return. Administering oxygen via nasal cannula (Choice C) may help with oxygenation but does not directly address reducing venous return. Increasing the client's activity level (Choice D) may worsen heart failure symptoms by increasing the workload on the heart.

5. In a patient with chronic kidney disease, which of the following is a common complication?

Correct answer: A

Rationale: Hyperkalemia is a common complication in chronic kidney disease due to the kidneys' reduced ability to excrete potassium. As kidney function declines, potassium levels may increase, leading to hyperkalemia. Hypernatremia (increased sodium levels), hypocalcemia (low calcium levels), and hyperphosphatemia (elevated phosphate levels) are not typically associated with chronic kidney disease. Therefore, the correct answer is hyperkalemia.

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