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 C

Explanation

A. This is a valid recommendation, especially for clients with asthma and bronchitis, as avoiding crowded areas can help reduce the risk of respiratory infections. However, while important, this option does not directly address the client’s current symptoms of mucus production and breathlessness.
B. Teaching anxiety reduction techniques can be beneficial, particularly if the client is experiencing feelings of suffocation or panic due to breathing difficulties. However, addressing anxiety alone will not resolve the immediate physical issues related to mucus clearance and shortness of breath.
C. This is the most important instruction for the client. Increasing fluid intake helps to thin out thick, tenacious mucus, making it easier to expectorate. This can significantly improve airway clearance and reduce shortness of breath, addressing the underlying problem the client is facing.
D. While it is essential for clients to be aware of medication side effects and to communicate with their healthcare provider, this option does not address the immediate self-care needs related to the client’s current respiratory symptoms.

A. Explain to the client that antibiotics are not useful in treating viral infections such as influenza. B. Instruct the client that over-the-counter medications are sufficient to manage Influenza symptoms. C. Advise the client that once symptoms occur it is too late to receive an influenza vaccination. D. Refer the client to the healthcare provider at the clinic to obtain a medication prescription.

Correct Answer is D

Explanation

A. While this statement is accurate regarding antibiotics and their ineffectiveness against viral infections, it does not directly address the client’s question about oseltamivir, which is an antiviral medication, not an antibiotic. This option might confuse the client rather than provide helpful information about their specific situation.
B. Over-the-counter medications can help alleviate some symptoms of influenza (like fever, aches, and congestion), but they do not treat the underlying viral infection or shorten its duration. For clients at high risk for complications (such as those with chronic health conditions), antiviral treatment like oseltamivir may be more appropriate.
C. This statement is accurate; the influenza vaccine is most effective when given before exposure to the virus. However, it doesn’t address the client's inquiry about oseltamivir or its appropriateness as a treatment once symptoms have developed.
D. Oseltamivir is most effective when taken within the first 48 hours of symptom onset, so referring the client for a prescription is appropriate if they are eligible for antiviral treatment. The healthcare provider can assess the client's symptoms, medical history, and need for antiviral therapy.

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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

Correct Answer is C

Explanation

A client with symptoms of Influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?

Correct Answer is D

Explanation

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