A client with emphysema is reporting difficulty breathing and exhibiting 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?

Throat irritation

Uncontrollable shaking

Irregular rapid heart rate

Increased anxiety

Answer and Explanation

The Correct Answer is C

Choice A reason: Throat irritation is a common albuterol side effect due to its deposition in the oropharynx during inhalation. It is not life-threatening and can be managed with rinsing or spacer use. This does not require immediate intervention compared to cardiovascular effects, as it does not compromise vital organ function.

Choice B reason: Uncontrollable shaking (tremors) is a frequent albuterol side effect, resulting from beta-2 receptor stimulation in skeletal muscles. It is usually transient and benign, not requiring immediate intervention. Monitoring is sufficient unless severe, as it does not pose an acute threat compared to cardiac irregularities.

Choice C reason: An irregular rapid heart rate (tachycardia or arrhythmia) is a serious albuterol side effect, as beta-2 agonists can stimulate beta-1 receptors in the heart, causing cardiovascular instability. This warrants immediate intervention, as it risks cardiac compromise, especially in emphysema patients with compromised respiratory and cardiac reserves.

Choice D reason: Increased anxiety is a possible albuterol side effect due to its stimulatory effects on the central nervous system. While distressing, it is not immediately life-threatening. It requires monitoring but is secondary to cardiovascular complications, which pose a greater acute risk in emphysema patients with wheezing.

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Correct Answer is D

Explanation

Choice A reason: A foreign body in the eye may cause irritation or damage but is not a contraindication for ketorolac, a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation. The nurse would ensure removal of the foreign body first, but ketorolac can be used post-removal if indicated.

Choice B reason: Radiation exposure, such as from UV light, may cause photokeratitis but is not a specific contraindication for ophthalmic ketorolac. The medication reduces inflammation and pain, which may be beneficial in such cases. The nurse should assess for other ocular conditions, but radiation exposure alone does not preclude its use.

Choice C reason: Chemical burns require immediate irrigation and specific treatments based on the chemical involved. Ketorolac may reduce pain and inflammation post-irrigation, but it is not contraindicated. The nurse should prioritize burn management, but chemical burns do not inherently prohibit ketorolac use compared to corneal abrasions.

Choice D reason: Corneal abrasions are a contraindication for ophthalmic ketorolac, as NSAIDs can delay corneal healing and increase the risk of complications like corneal ulceration. The nurse must review the medical record to confirm the absence of abrasions, as ketorolac is typically used for postoperative pain, not traumatic corneal injuries.

A. Obtain an arterial blood gas prior to the procedure B. Perform the drainage immediately after meals C. Instruct the client to breathe shallow and fast D. Explain that the client may be placed in five positions

Correct Answer is D

Explanation

Choice A reason: Obtaining an arterial blood gas assesses oxygenation and acid-base status, useful in COPD management, but is not required before postural drainage. This invasive procedure is unnecessary for routine drainage, which mobilizes secretions. Explaining positions prepares the client, enhancing cooperation and effectiveness.

Choice B reason: Performing drainage after meals risks aspiration or vomiting, as a full stomach increases intra-abdominal pressure in COPD patients. Postural drainage is most effective when performed on an empty stomach, making this approach incorrect. Patient education on positioning is the priority.

Choice C reason: Shallow, fast breathing is counterproductive in COPD, as it reduces tidal volume and worsens hypercapnia. Postural drainage requires slow, deep breaths to mobilize secretions and improve ventilation. Explaining positions ensures proper technique, making this breathing instruction incorrect.

Choice D reason: Explaining that the client may be placed in five positions (e.g., prone, supine, lateral) prepares them for postural drainage, which uses gravity to mobilize lung secretions in COPD. This education enhances compliance and effectiveness, as proper positioning is critical for therapeutic success, making it the correct approach.

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A client with emphysema is reporting difficulty breathing and exhibiting 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

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