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 this is a good suggestion for managing duodenal ulcers, it doesn't directly address the issue of dairy products. Dairy products, especially milk and cream, can stimulate gastric acid secretion and worsen duodenal ulcer symptoms.
B. The nurse should clarify that while dairy products may seem beneficial, they can actually exacerbate duodenal ulcers. The client should be advised to avoid or limit foods rich in milk and cream.
C. While caffeine can irritate the stomach and worsen ulcer symptoms, this is not the most important point to address in this situation. The primary concern is the client's belief that dairy products will help protect the ulcer, which is incorrect.
D. This would be counterproductive. The nurse should be discouraging the client from consuming dairy products, not encouraging them.

Correct Answer is ["100"]

Explanation

Infusion rate (mL/hr)= Total volume (mL)/ Time (hr)

Infusion rate = 100mL/1 hr

Thus, you would set the infusion pump to 100 mL/hr to deliver the medication over one hour.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow up action by the nurse?

Correct Answer is B

Explanation

A client receives a prescription for vancomycin 500 mg IV every 8 hours. The medication is provided in, "500 mg per 100 mL of dextrose 5% in water." To administer the medication over an hour, the nurse should set the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

Correct Answer is ["100"]

Explanation

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