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    HESI RN Medical Surgical Proctored Exam
    Select All That Apply

    Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

    Explanation & Rationale

    A. The patient’s oxygen saturation remains below the target of 94% despite initial oxygen therapy. Therefore, increasing the oxygen flow might be necessary to achieve better oxygenation. B. Since the patient remains symptomatic with ongoing wheezes, administering another dose of the nebulizer treatment as ordered, since the prescription included PRN can help to further open the airways and alleviate wheezing. C. Elevating the head of the bed can help improve lung expansion and ease the work of breathing, which is particularly beneficial in respiratory distress situations. D. Switching to a nonrebreather mask may be appropriate if the patient’s oxygen saturation does not improve sufficiently with the current method of oxygen delivery. This type of mask can deliver a higher concentration of oxygen. E. While incentive spirometry is generally used for preventing pulmonary complications (such as pneumonia or atelectasis) after surgery or in conditions where patients are likely to be immobile, it may not be immediately beneficial or a priority in the acute management of an asthma attack. The primary focus should be on stabilizing the patient’s respiratory status through medication and oxygen therapy. Thus, this option is less critical at this stage. F. Continuous monitoring of vital signs is crucial in acute cases like this to assess the patient's response to interventions and detect any deterioration in the clinical status.

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