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    Ati lpn med surg respiratory proctored exam

    A nurse is caring for a client who has been admitted with asthma exacerbation and is experiencing increased wheezing and has an oxygen saturation of 91%. The client is scheduled for his next breathing treatment in 1hr. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Requesting the pharmacy to dispense 10 mL of dextromethorphan PO: Dextromethorphan is an antitussive used to suppress cough. It does not relieve bronchospasm or improve oxygenation in an asthma exacerbation and is not appropriate for acute wheezing or hypoxemia. B. Increasing oxygen to maintain an oxygen saturation of 95% or greater in the client: While supplemental oxygen may be necessary to maintain adequate oxygenation, the priority in acute asthma with wheezing and low oxygen saturation is to relieve bronchospasm with a bronchodilator. Oxygen alone does not address the underlying airway obstruction. C. Instructing respiratory therapy to administer a PRN albuterol aerosol: Administering a short-acting bronchodilator such as albuterol is the most appropriate action. It acts quickly to relieve bronchospasm, improve airflow, and increase oxygen saturation during an acute asthma exacerbation. D. Asking the provider to repeat another radiograph of the chest: A chest radiograph may be indicated if complications or differential diagnoses are suspected, but it does not provide immediate relief of bronchospasm or improve oxygenation during an acute asthma attack.

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