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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. While auscultating bowel sounds can provide information about bowel function and potential ileus, it is not a specific requirement before administering vancomycin. This action may be helpful but does not directly relate to the safety or efficacy of the medication.
B. Vancomycin is known for its potential nephrotoxicity, especially when used intravenously. While the oral route of administration for C. difficile infection generally poses less risk to renal function, checking serum creatinine levels is a prudent step to ensure that the client’s renal function is adequate and to establish a baseline, especially if the client has other risk factors for kidney impairment.
C. Assessing body temperature can be important in monitoring the client’s infection and response to treatment. However, it is not a specific requirement before administering vancomycin. While useful, it doesn’t provide critical information related to the safety of the medication itself.
D. Measuring oxygen saturation is typically important in clients with respiratory issues or those showing signs of respiratory distress. However, it is not directly related to administering vancomycin for C. difficile infection. This action may not be necessary unless the client has respiratory concerns.

A. Apply a hydrocolloidal gel dressing. B. Increase the frequency of the dressing changes. C. Leave the dressing off until consulting with the healthcare provider. D. Replace the gauze with a transparent dressing.

Correct Answer is D

Explanation

A. This option may be appropriate for some types of wounds, but given that the wound is already showing significant granulation, a hydrocolloidal dressing might not be the best choice. Transparent dressings are often preferred for wounds with granulation as they are less likely to damage the tissue when changed.
B. Increasing the frequency of dressing changes is generally not indicated unless there is excessive drainage or a risk of infection. Overchanging dressings can disrupt the healing process and expose the wound to potential contaminants.
C. Leaving the dressing off can expose the wound to infection and may disrupt the healing process. It is important to maintain a protective barrier over the wound while consulting with the provider.
D. A transparent dressing allows for visualization of the wound while providing a moist environment that promotes healing and protects the granulation tissue. It can also minimize friction and trauma to the wound.

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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?

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Naxlex Comprehensive Predictor Exams

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

Correct Answer is B

Explanation

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is D

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

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