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    Hesi RN Exit Proctored ExamQuestion 126
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    Hesi RN Exit Proctored Exam
    Select All That Apply

    Exhibits The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

    Explanation & Rationale

    A. While discussing treatment options is important, it may not be immediately necessary at this point unless the client shows signs of severe respiratory distress or failure. B. Given the client's respiratory distress and recent cold symptoms, obtaining a sputum culture can help identify any underlying infection, which is important for appropriate treatment, particularly with the prescribed azithromycin. C. Continuous monitoring of oxygen saturation is essential to ensure that the client's oxygen levels are adequate, especially since she is at risk for hypoxia. The goal is to maintain oxygen saturation greater than 94%. D. Positioning the client in a way that enhances her comfort, such as sitting upright, can help improve her breathing and reduce respiratory distress. This is a fundamental nursing intervention in respiratory care. E. If the client's oxygen saturation improves, the nurse can begin to wean the supplemental oxygen while monitoring for any signs of respiratory distress. This step should be approached cautiously to ensure the client maintains adequate oxygen levels. F. There is no indication that the client requires deep tracheal suctioning at this moment. This action is reserved for patients with excessive secretions or compromised airway patency. G. Positive pressure ventilation would typically be considered if the client were in severe respiratory distress or failure. The current assessment does not indicate an immediate need for this intervention. H. Education on potential asthma triggers is crucial for the client's long-term management. This discussion can help the client avoid situations that could lead to future exacerbations, thus improving her overall asthma control.

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