A client is receiving oxygen via a non-rebreather mask. What is the most important nursing assessment?

Correct Answer: A

Rationale: The correct answer is A: Ensuring the reservoir bag remains inflated. This is crucial as it indicates the client is receiving the intended high-flow oxygen without rebreathing exhaled CO2. If the bag deflates, it suggests a leak or inadequate flow. Option B is not relevant as the flow rate for a non-rebreather mask is typically higher. Option C is less critical than ensuring oxygen delivery. Option D is important but not the priority when the client's oxygenation is at stake.

Correct Answer: A

Rationale: The correct answer is A: Decreased wheezing on auscultation. Wheezing is a common symptom of asthma due to narrowed airways. Improvement in asthma would lead to decreased wheezing as the airways open up, allowing for better airflow. This indicates that the bronchodilator is effectively working to dilate the airways and improve respiratory function. Choice B: Respiratory rate increased to 24 breaths per minute is incorrect as an increased respiratory rate could indicate respiratory distress or worsening of asthma symptoms. Choice C: Heart rate increased to 110 beats per minute is incorrect as an increased heart rate could indicate stress or anxiety, not necessarily improvement in asthma. Choice D: Mild hand tremors reported by the client is incorrect as hand tremors are a common side effect of bronchodilators and not a direct indicator of asthma improvement.

Correct Answer: C

Rationale: The correct answer is C: Keep the patient NPO until the gag reflex returns. After a bronchoscopy with biopsy, the patient's throat and gag reflex may be impaired due to the procedure and anesthesia. Keeping the patient NPO until the gag reflex returns is crucial to prevent aspiration and ensure safe swallowing. Encouraging clear liquids (A) may pose a risk of aspiration if the gag reflex is not intact. Bed rest (B) may not be necessary unless there are specific complications. Maintaining the head of the bed elevated (D) is generally advised for respiratory comfort but is not the immediate priority post-procedure.

Correct Answer: B

Rationale: The correct answer is B: Albuterol (Ventolin HFA) 2.5 mg per nebulizer. In an acute asthma attack, the priority is to quickly open the airways to improve breathing. Albuterol is a short-acting beta agonist that acts rapidly to bronchodilate and relieve bronchospasm. Administering it via nebulizer allows for fast delivery and effective relief. Methylprednisolone (A) is a corticosteroid that helps reduce inflammation but works more slowly and is typically given after initial bronchodilator therapy. Salmeterol (C) is a long-acting beta agonist not used for immediate relief in acute attacks. Ipratropium (D) is an anticholinergic that can also help with bronchodilation but is not the first-line treatment for acute asthma exacerbations.

Correct Answer: C

Rationale: The correct answer is C because taking antibiotics for influenza is ineffective as influenza is a viral infection, not bacterial. Antibiotics only work against bacteria. Step 1: Influenza is caused by a virus. Step 2: Antibiotics do not treat viral infections. Step 3: Taking antibiotics for influenza will not help. Summary: A, B, and D are correct strategies for reducing influenza transmission, while C is incorrect as antibiotics are not appropriate for treating influenza.