37. Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report
immediately to the health care provider?
a. Pain at injection site c. Peak flow reading 75% of normal
b. Flushing and dizziness d. Respiratory rate 24 breaths/minute
ANS: B
Flushing and dizziness may indicate that the patient is experiencing an anaphylactic reaction, and immediate
intervention is needed. The other information should also be reported, but do not indicate possibly life-
threatening complications of omalizumab therapy.
38. The nurse in the emergency department receives arterial blood gas results for four recently admitted
patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by
the nurse?
a. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg
b. pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg
c. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg
d. pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
ANS: A
The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and
hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis.
OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients
39. Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse
delegate to experienced unlicensed assistive personnel (UAP)?
a. Obtain O2 saturation using pulse oximetry.
b. Monitor lfor lincreased lO2 lneed lwith lexercise.
c. Teach lthe lpatient labout lsafe luse lof lO2 lat lhome.
d. Adjust lO2 lto lkeep lsaturation lin lprescribed
lparameters. lANS: lA
UAP lcan lobtain lO2 lsaturation l(after lbeing ltrained land levaluated lin lthe lskill). l The lother lactions
lrequire lmore leducation land la lscope lof lpractice lthat llicensed lpractical/vocational lnurses l(LPN/LVNs)
lor lregistered lnurses l(RNs) lwould lhave.
OBJ: lSpecial lQuestions: lDelegation l40. lThe lclinic lnurse lmakes la lfollow-up ltelephone lcall lto la lpatient
lwith lasthma. lThe lpatient lreports lhaving la lbaseline lpeak lflow lreading lof l600 lL/min, land lthe lcurrent lpeak
lflow lis l420 lL/min. lWhich laction lshould lthe lnurse ltake lfirst?
a. Tell lthe lpatient lto lgo lto lthe lhospital lemergency ldepartment.
b. Instruct lthe lpatient lto luse lthe lprescribed lalbuterol l(Ventolin lHFA).
c. Ask labout lrecent lexposure lto lany lnew lallergens lor lasthma ltriggers.
,d. Question lthe lpatient labout luse lof lthe lprescribed linhaled
lcorticosteroids. lANS: lB
The lpatient’s lpeak lflow lis l70% lof lnormal, lindicating la lneed lfor limmediate luse lof lshort-acting lb2-
adrenergic lSABA lmedications. lAssessing lfor lcorrect luse lof lmedications lor lexposure lto lallergens lis lalso
lappropriate, lbut lwould lnot laddress lthe lcurrent ldecrease lin lpeak lflow. lBecause lthe lpatient lis lcurrently lin
lthe lyellow lzone, lhospitalization lis lnot lneeded.
OBJ: lSpecial lQuestions: lPrioritization l41. lThe lnurse lreviews lthe lmedication ladministration lrecord l(MAR)
lfor la lpatient lhaving lan lacute lasthma lattack. lWhich lmedication lshould lthe lnurse ladminister lfirst?
a. Methylprednisolone l(Solu-Medrol) l60 lmg lIV
b. Albuterol l(Ventolin lHFA) l2.5 lmg lper lnebulizer
c. Salmeterol l(Serevent) l50 lmcg lper ldry-powder linhaler l(DPI)
d. Ipratropium l(Atrovent) l2 lpuffs lper lmetered-dose linhaler
l(MDI) lANS: lA
Albuterol lis la lrapidly lacting lbronchodilator land lis lthe lfirst-line lmedication lto lreverse lairway lnarrowing
lin lacute lasthma lattacks. lThe lother lmedications lwork lmore lslowly.
OBJ: lSpecial lQuestions: lPrioritization l42. lThe lnurse lreceives la lchange-of-shift lreport lon lthe lfollowing
lpatients lwith lchronic lobstructive lpulmonary ldisease l(COPD). lWhich lpatient lshould lthe lnurse lassess
lfirst?
a. lA lpatient lwith lloud lexpiratory lwheezes
b. lA lpatient lwith la lrespiratory lrate lof l38 lbreaths/min
c. lA lpatient lwho lhas la lcough lproductive lof lthick, lgreen lmucus
d. lA lpatient lwith ljugular lvenous ldistention land lperipheral ledema
lANS: lB
A lrespiratory lrate lof l38/min lindicates lsevere lrespiratory ldistress, land lthe lpatient lneeds limmediate
lassessment land lintervention lto lprevent lpossible lrespiratory larrest. lThe lother lpatients lalso lneed
lassessment las lsoon las lpossible, lbut lthey ldo lnot lneed lto lbe lassessed las lurgently las lthe lpatient lwith
ltachypnea.
OBJ: lSpecial lQuestions: lPrioritization l| lSpecial lQuestions: lMultiple lPatients
43. Which lfinding lin la lpatient lhospitalized lwith lbronchiectasis lis lmost limportant lto lreport lto lthe lhealth
lcare lprovider?
a. Cough lproductive lof lbloody, lpurulent lmucus
b. Scattered lcrackles land lwheezes lheard lbilaterally
c. Complaint lof lsharp lchest lpain lwith ldeep lbreathing
d. Respiratory lrate l28 lbreaths/minute lwhile
lambulating lANS: lA
, Hemoptysis lmay lindicate llife-threatening lhemorrhage, land lshould lbe lreported limmediately lto
lthe lhealth lcare lprovider. lThe lother lfindings lare lfrequently lnoted lin lpatients lwith lbronchiectasis
land lmay lneed lfurther lassessment lbut lare lnot lindicators lof llife-threatening lcomplications.
COMPLETION
ALL lHESI lLINKS lAVAILABLE
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