a client is experiencing acute bronchospasm what is the nurses priority intervention
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet Capstone

1. A client is experiencing acute bronchospasm. What is the nurse's priority intervention?

Correct answer: A

Rationale: The correct answer is to administer a nebulizer treatment of albuterol. In acute bronchospasm, the priority intervention is to deliver a bronchodilator like albuterol to open the airways and improve breathing. Starting an IV infusion of normal saline (Choice B) may be necessary but not the priority in this situation. Administering oxygen at 4L/min via nasal cannula (Choice C) is important but not the first intervention for bronchospasm. Positioning the client in a high Fowler's position (Choice D) can help with breathing but is not the priority over administering a bronchodilator.

2. A client is being prepared for surgery and has been placed on NPO status. Which of the following is the nurse's priority assessment?

Correct answer: B

Rationale: The correct answer is B. Monitoring the client's compliance with NPO status is the priority assessment. Ensuring the client remains NPO (nothing by mouth) is crucial to reduce the risk of aspiration during surgery. Assessing the client's understanding of the procedure is important but not the priority at this moment. Checking vital signs is also essential but ensuring NPO status takes precedence for patient safety. Ensuring the client's consent form is signed is necessary but not the priority assessment compared to maintaining NPO status.

3. A client asks the nurse to call the police and states: 'I need to report that I am being abused by a nurse.' The nurse should first

Correct answer: C

Rationale: The correct initial action for the nurse is to obtain more details about the client's claim of abuse. This will help the nurse better understand the situation before proceeding with any further actions. Option A is incorrect as reality orientation is not the priority in this situation. Option B is premature as more details are needed first. Option D is not the immediate step as gathering information should come before documentation and reporting.

4. A client with pneumonia is prescribed antibiotics. What is the most important teaching point for the nurse to provide?

Correct answer: C

Rationale: The correct answer is C. Antibiotics must be taken for the entire prescribed duration to ensure that the infection is completely eradicated. Stopping antibiotics early, even if symptoms improve, can lead to a recurrence of the infection or antibiotic resistance. Choice A is incorrect because though rest is important, completing the antibiotic course is crucial. Choice B is incorrect as while hydration is beneficial, completing the antibiotics is the priority. Choice D is incorrect as stopping antibiotics prematurely can have negative consequences.

5. The nurse is developing an educational program for older clients discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics?

Correct answer: D

Rationale: The correct answer is D, 'All of the above.' When developing educational materials for older clients with new antihypertensive medications, it is essential to include characteristics such as using pictures to illustrate complex ideas, providing a list with definitions of unfamiliar terms, and using common words with few syllables. These features help enhance understanding and medication adherence, especially for older adults who may have challenges with health literacy. Choices A, B, and C collectively address the need for simplicity, visual support, and clarification of terms in educational materials, making them crucial for effective patient education.

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