NCLEX-PN® ExaminationReduction of Risk PotentialEasy
A client is experiencing an acute asthma exacerbation. The LPN notes the client is anxious, using accessory muscles to breathe, and has an oxygen saturation of 89% on room air. Which action should the LPN take FIRST?
- APlace the client in a high Fowler's position.
- BAdminister a prescribed bronchodilator via nebulizer.
- CNotify the registered nurse (RN) or healthcare provider.
- DObtain a complete set of vital signs.
Show answer & explanationAnswer & explanation
Correct answer: A. Place the client in a high Fowler's position.
Placing the client in a high Fowler's position immediately promotes lung expansion and eases breathing, which is a priority for a client in respiratory distress. While other actions are important, positioning is the quickest immediate intervention.
Why the other options are wrong
- B. Administering medication is important but positioning for comfort and easier breathing can be done immediately without delay.
- C. Notifying the RN/provider is crucial but not the absolute first action when immediate physical intervention can help.
- D. Obtaining vital signs is important for assessment but does not directly alleviate the client's immediate respiratory distress.
Acute Asthma Exacerbation
A sudden worsening of asthma symptoms, including shortness of breath, wheezing, and chest tightness, often requiring immediate intervention.
- Symptoms include dyspnea, wheezing, cough, accessory muscle use.
- Hypoxemia and anxiety are common.
- Immediate interventions focus on oxygenation and bronchodilation.
Memory trick: Airway first, then drugs and docs.