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 D
Explanation
A. Ketorolac is an anti-inflammatory medication that is not specifically contraindicated in the case of a chemical burn, but care should be taken.
B. There is no specific contraindication for ketorolac related to radiation exposure.
C. Ketorolac can be used in the presence of a foreign body, but caution is needed based on the type of injury.
D. A corneal abrasion is a condition where ketorolac may be contraindicated due to the risk of delayed healing; thus, reviewing the medical record for any history of corneal abrasion is crucial before administration.
Correct Answer is B
Explanation
A. Increasing intestinal peristalsis is not a primary goal related to managing a hiatal hernia. While peristalsis is important for digestion, the focus should be on the esophagus and stomach.
B. Preventing esophageal reflux is the main goal for clients with a hiatal hernia, especially sliding type, as the hernia can cause the stomach to push into the esophagus, leading to reflux symptoms. Strategies to prevent reflux may include dietary modifications and positioning.
C. Promoting effective swallowing may be important in some contexts, but it is not a primary goal associated with managing a hiatal hernia.
D. Maintaining intact oral mucosa is generally a broader nursing goal and not specific to the management of a hiatal hernia. The focus should be on preventing reflux rather than oral mucosa integrity in this case.
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