A client with emphysema is reporting a difficulty in breathing and exhibiting an audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?
Uncontrollable shaking.
Increased anxiety.
Irregular rapid heart rate.
Throat irritation.
The Correct Answer is C
A. This could indicate tremors, which are a common side effect of albuterol due to its action as a beta-2 agonist. While it can be uncomfortable for the client, it is generally not life-threatening and can be monitored unless it severely affects the client’s ability to function.
B. Increased anxiety can occur due to hypoxia, difficulty breathing, or as a side effect of albuterol. While concerning, it does not typically require immediate intervention unless it leads to further complications or severe distress.
C. Albuterol can cause tachycardia (rapid heart rate) and arrhythmias as side effects, particularly with frequent use. An irregular rapid heart rate can be indicative of significant cardiac distress and may lead to serious complications. This finding warrants immediate intervention as it poses a risk to the client’s safety and may indicate potential worsening of the condition or an adverse reaction to the medication.
D. Throat irritation can occur with inhaled medications and, while uncomfortable, it is generally not an urgent concern. It does not require immediate intervention unless it leads to significant complications like severe swelling or difficulty swallowing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Salt tablets can exacerbate hypernatremia by increasing sodium intake. Patients with hypernatremia should be advised to limit sodium intake.
B. While it's important to stay hydrated, drinking excessive water can lead to hyponatremia, especially in individuals with impaired renal function or heart failure. The goal is to maintain a balance between fluid intake and sodium intake.
C. Patients with hypernatremia need to be aware of the sodium content in the foods they eat. By reviewing food labels, they can make informed choices and limit their sodium intake.
D. While monitoring urine output can be helpful in assessing fluid status, it's not the most important discharge instruction for hypernatremia. The primary focus should be on managing sodium intake and maintaining fluid balance.
Correct Answer is B
Explanation
A. Shouting can be irritating and may not be effective in improving communication. It's better to speak at a normal volume but in a clear and distinct manner.
B. Hearing loss is a common problem among older adults and can affect their ability to communicate effectively. When communicating with a client with hearing loss, it's important to use clear and concise language, speak slowly and distinctly, and face the client directly.
C. Over-enunciating can make it difficult for the client to understand the words, especially if they have hearing loss. It's better to speak clearly and distinctly without exaggerating the pronunciation of each syllable.
D. Nonverbal communication can be helpful, but it's not a substitute for clear and effective verbal communication. It's important to use both verbal and nonverbal communication to ensure that the client understands what is being said.
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