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 C

Explanation

A. While knowing the last dose of corticosteroids may be relevant, it does not address the immediate symptoms of confusion and vomiting.
B. Establishing a neurological baseline is important, but the priority is to manage the client's acute symptoms first.
C. Administering a PRN IV antiemetic is essential to manage the projectile vomiting, which can lead to further complications like aspiration or dehydration. This intervention directly addresses the client's current distress.
D. A complete head-to-toe neurological assessment is important for ongoing monitoring, but it should be conducted after stabilizing the client's immediate symptoms.

A. Positioning the client with the head of the bed elevated B. Avoid treating fever with antipyretics C. Encourage the client to take breaks from the oxygen mask every few hours D. Providing suctioning so the client does not have to cough E. Assist the client in ambulating safely F. Asking the client to do quick, shallow breaths G. Teaching the client to cough at least once an hour

Correct Answer is ["A","E","G"]

Explanation

A. Positioning the client with the head of the bed elevated helps improve lung expansion and facilitates better ventilation and oxygenation, reducing the work of breathing.
B. Avoid treating fever with antipyretics is not appropriate, as managing fever can help reduce metabolic demand and improve overall comfort, which aids in ventilation.
C. Encouraging the client to take breaks from the oxygen mask is not advisable, as consistent oxygen delivery is critical for maintaining adequate oxygen saturation, especially in cases of pneumonia.
D. Providing suctioning so the client does not have to cough may not be necessary; coughing is a natural mechanism to clear secretions and improve airway patency.
E. Assisting the client in ambulating safely promotes lung expansion, enhances circulation, and aids in the mobilization of secretions, contributing positively to ventilation and oxygenation.
F. Asking the client to do quick, shallow breaths is counterproductive, as it can lead to inadequate ventilation and decreased oxygenation; deep breathing is preferred.
G. Teaching the client to cough at least once an hour is essential for clearing secretions and improving lung function, thereby enhancing ventilation and oxygenation.

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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 with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

Exhibits Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Correct Answer is ["A","E","G"]

Explanation

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