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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Securing a disposable collar is not the most important action during the tie change.
B. Leaving the old tube in place until the new ones are secure is critical to maintain the airway and prevent accidental dislodgement of the tracheostomy tube, ensuring the client can breathe effectively during the procedure.
C. Placing knots laterally may help reduce irritation but does not address the immediate concern of securing the airway during the tie change.
D. Securing ties close to the tube can lead to pressure injuries and irritation but is not the priority compared to ensuring airway security.

A. Trouble sleeping. B. Recent oral intake. C. Unexplained weight loss. D. Difficulty with urination.

Correct Answer is B

Explanation

A. Trouble sleeping may be relevant to the client's overall health but does not directly impact the administration of pyridostigmine.
B. Recent oral intake is crucial to determine if the client can swallow effectively, as pyridostigmine can affect muscle strength, including those involved in swallowing.
C. Unexplained weight loss could indicate other issues but is not immediately pertinent to the administration of this medication.
D. Difficulty with urination may be important for other reasons but does not directly relate to the effects or administration of pyridostigmine.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

Correct Answer is B

Explanation

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

Correct Answer is B

Explanation

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?

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