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 C
Explanation
A. Eye drops for glaucoma are not used for pain and swelling control but to manage intraocular pressure.
B. Open-angle glaucoma is not about restoring a smaller angle; it is managed primarily by controlling intraocular pressure.
C. Long-term use of eye drops is necessary for maintaining normal eye pressure and preventing optic nerve damage in clients with open-angle glaucoma.
D. While the drops may reduce excess pressure initially, lifelong treatment is generally required to maintain safe pressure levels and prevent further damage.
Correct Answer is C
Explanation
A. Observing body language and movement can provide clues about the client's pain but does not directly assess the quality of the pain experienced.
B. Identifying effective pain relief measures is important for managing pain but does not assess the quality of pain itself.
C. Asking the client to describe the pain directly assesses its quality, allowing the nurse to understand its characteristics, such as intensity, duration, and type (e.g., sharp, dull, throbbing).
D. Providing a numeric pain scale is useful for quantifying pain intensity but does not capture the qualitative aspects of the pain experience.
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