a client presents to the emergency room with an acute asthma attack what is the nurses priority intervention
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet Capstone

1. A client presents to the emergency room with an acute asthma attack. What is the nurse's priority intervention?

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as prescribed. During an acute asthma attack, the priority is to open the airways quickly to help the client breathe more easily. Oxygen may be needed but bronchodilators take precedence as they directly target bronchoconstriction. Chest physiotherapy is not indicated in the acute phase of asthma and may exacerbate the condition. While emotional support is important, addressing the airway obstruction takes precedence in this situation.

2. A client with a recent myocardial infarction is prescribed a beta-blocker. What side effect should the nurse monitor for?

Correct answer: B

Rationale: The correct answer is B: 'Check the client’s blood pressure for signs of hypotension.' Beta-blockers can lead to decreased heart rate, but bradycardia is not the primary side effect to monitor. Monitoring for bradycardia is more relevant when administering medications like digoxin. Hyperglycemia is associated with medications like corticosteroids, not beta-blockers. Fluid retention is a side effect seen with medications like corticosteroids or calcium channel blockers, not beta-blockers. Therefore, in a client taking a beta-blocker after a myocardial infarction, monitoring for hypotension is crucial due to the medication's mechanism of action.

3. The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement?

Correct answer: A

Rationale: In some cases, the smell of food cooking can trigger nausea in cancer patients. Cooking food outside reduces the intensity of odors that could trigger nausea, helping the client maintain adequate nutrition. Providing anti-nausea medication (Choice B) may not address the root cause of the nausea triggered by the smell of cooking food. Suggesting cold water (Choice C) or smaller, frequent meals (Choice D) may not directly address the issue of cooking odors triggering nausea, which is specific to this client's situation.

4. A client with a history of type 2 diabetes is admitted with hyperglycemia. What is the nurse's priority action?

Correct answer: B

Rationale: The correct answer is to check the client's blood glucose level. This is the priority action when dealing with a client admitted with hyperglycemia. Checking the blood glucose level helps determine the severity of hyperglycemia and guides further treatment. Administering insulin or fluids or monitoring intake and output are important interventions but should come after assessing the blood glucose level to inform the most appropriate course of action.

5. A client receiving heparin therapy develops sudden chest pain and dyspnea. What should the nurse do first?

Correct answer: A

Rationale: In this scenario, the priority action for the nurse is to administer oxygen and elevate the head of the bed. These interventions help relieve dyspnea and chest pain, which can be indicative of a pulmonary embolism or other complications during heparin therapy. Administering nitroglycerin (Choice B) is not the initial priority in this situation as the client's symptoms are not suggestive of angina. Assessing for bleeding (Choice C) is important but not the first action needed to address chest pain and dyspnea. Administering albuterol (Choice D) is not indicated unless there are specific respiratory issues requiring it, which are not described in the scenario.

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