A client with emphysema is reporting difficulty in 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?
Uncontrollable shaking.
Increased anxiety.
Throat irritation.
Irregular rapid heart rate.
The Correct Answer is D
A. Uncontrollable shaking can be a side effect of albuterol, but it is not as critical as other potential cardiovascular concerns.
B. Increased anxiety is common with respiratory distress but is not immediately life-threatening.
C. Throat irritation may occur but is generally not a severe concern compared to cardiovascular effects.
D. An irregular rapid heart rate is a significant sign of potential adverse effects from albuterol, indicating possible toxicity or worsening of the client’s condition, which requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Storing the medication at room temperature is appropriate and indicates correct understanding.
B. Priming the inhaler with 7 pumps is excessive. Generally, ipratropium inhalers require only 2-3 pumps to prime before first use, indicating that the client needs additional teaching on the proper priming technique.
C. Attaching a spacer device is a beneficial action that can enhance medication delivery and is recommended for use with metered-dose inhalers.
D. Rinsing the mouth after each use is good practice to minimize the risk of oral side effects, such as dryness or irritation.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}
Explanation
- Oxygen saturation greater than 94% indicates improved oxygenation, showing the treatment's effectiveness.
- PaCO2 55 mm Hg per arterial blood gas indicates hypercapnia, suggesting ineffective treatment as normal levels should be lower.
- Symmetric chest expansion suggests effective treatment as it reflects improved lung function.
- Rhonchi in the right lung may indicate retained secretions, suggesting ineffective treatment.
- Client ambulates without shortness of breath demonstrates effective treatment, as the patient can move without respiratory distress.
- Diminished breath sounds in the right lung could indicate ongoing consolidation or fluid, suggesting ineffective treatment.
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