A client with pneumonia who has an emergent episode of respiratory distress is intubated and transferred to the intensive care unit. The client's chest x-ray shows consolidation in the left lobe, and physical assessment reveals diminished lung sounds. The nurse administers acetylcysteine as prescribed per nebulization via endotracheal tube. Which therapeutic response of this medication should the nurse expect?

Bronchodilation and wheezing.

Unpleasant smell when using the medication.

Increased sputum, requiring suctioning.

Hypotension.

Answer and Explanation

The Correct Answer is C

Choice C reason: Acetylcysteine is a mucolytic agent that breaks down mucus and makes it easier to cough up or suction out. This helps to clear the airways and improve oxygenation. The nurse should expect to see increased sputum production after administering acetylcysteine and provide frequent suctioning as needed.

Choice A reason: Bronchodilation and wheezing are not therapeutic responses of acetylcysteine, but rather possible adverse effects. Acetylcysteine can cause bronchospasm or bronchoconstriction in some clients, especially those with asthma or chronic obstructive pulmonary disease (COPD). The nurse should monitor the client's breath sounds and oxygen saturation and report any signs of respiratory distress.

Choice B reason: Unpleasant smell when using the medication is not a therapeutic response of acetylcysteine, but rather a common side effect. Acetylcysteine has a rotten egg odor that can be unpleasant for both the client and the nurse. The nurse can minimize this by using a mouthwash or a flavored lozenge before and after administering acetylcysteine.

Choice D reason: Hypotension is not a therapeutic response of acetylcysteine, but rather a rare but serious adverse effect. Acetylcysteine can cause vasodilation or hypovolemia in some clients, leading to low blood pressure and shock. The nurse should monitor the client's vital signs and report any signs of hypotension.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Ferrous sulfate is best absorbed on an empty stomach, so waiting 2 hours after meals to take the tablet will enhance its effectiveness. Food can interfere with iron absorption, especially dairy products, eggs, coffee, tea, and antacids.

Choice B reason: Bedtime is not the best time to take the tablet, because lying down after taking iron can cause gastrointestinal upset, such as nausea, vomiting, constipation, or diarrhea. The client should take the tablet with a full glass of water and remain upright for at least 30 minutes.

Choice C reason: Taking the tablet with a daily multivitamin is not recommended, because some vitamins and minerals can reduce iron absorption, such as calcium, zinc, copper, and vitamin E. The client should avoid taking iron with other supplements unless advised by the healthcare provider.

Choice D reason: Crushing the tablets and mixing with pudding is not advisable, because enteric-coated tablets are designed to dissolve slowly in the intestine and protect the stomach from irritation. Crushing them will destroy their coating and reduce their effectiveness. The client should swallow the tablets whole and not chew or crush them.

A. Determine when the last dose was administered. B. Encourage the client to use diversional thoughts to manage pain. C. Ask the client to rate the current level of pain using a pain scale. D. Review the history for a past use of recreational drugs.

Correct Answer is C

Explanation

Choice A reason: Determining when the last dose was administered is important to ensure safe and effective pain management, but it is not the first action that the nurse should implement. The nurse should first assess the client's pain level and intensity before deciding on the appropriate dose and frequency of pain medication.

Choice B reason: Encouraging the client to use diversional thoughts to manage pain is a non-pharmacological intervention that can help reduce pain perception and anxiety, but it is not sufficient to address severe or acute pain. The nurse should first assess the client's pain level and intensity before suggesting any complementary or alternative therapies.

Choice C reason: Asking the client to rate the current level of pain using a pain scale is the first action that the nurse should implement, as it can help quantify and communicate the client's pain experience and guide the nurse's decision on pain medication. The nurse should use a valid and reliable pain scale that is appropriate for the client's age, cognitive ability, and language preference.

Choice D reason: Reviewing the history for a past use of recreational drugs is relevant to assess the client's risk of addiction or tolerance to pain medication, but it is not the first action that the nurse should implement. The nurse should first assess the client's pain level and intensity before considering any factors that may influence pain management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult with iron deficiency anemia is being discharged with a prescription for ferrous sulfate enteric-coated tablets. To promote best absorption of the medication, which information should the nurse include in the discharge instructions?

Correct Answer is A

Explanation

A client in the surgical recovery area asks the nurse to bring the largest possible dose of pain medication available. Which action should the nurse implement first?

Correct Answer is C

Explanation

A female client with multiple sclerosis reports having less fatigue and improved memory since she began using the herbal supplement, ginkgo biloba. Which information is most important for the nurse to include in the teaching plan for this client?

A client with Parkinson's disease who is taking carbidopa/levodopa reports that urine appears to be darker in color. Which action should the nurse take?

The nurse prepares to administer a scheduled dose of labetalol by mouth to a client with hypertension. The client's vital signs are temperature 99°F (37.22°C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (B/P) 150/90 mm Hg. Which action should the nurse take?

The nurse initiates an infusion of piperacillin-tazobactam for a client with a urinary tract infection. Five minutes into the infusion, the client reports not feeling well. Which client manifestation should the nurse identify as a reason to stop the infusion?

After receiving five doses of filgrastim, the nurse notes that the client's white blood cell count has increased from 2,500/mm3 (2.5 x 109/L) to 5,000/mm3 (5 x 109/L). Which action should the nurse implement? White Blood Cell (WBC) [Reference Range: 5000 to 10,000/mm3 (5 to 10 x 109/L)]

The healthcare provider prescribes the antibiotic tetracycline HCl for an adult client that arrived at an outpatient clinic. Which instruction should the nurse include in the teaching plan for this client?

The nurse is planning the home care of a client who is receiving a mydriatic medication. Which environment is best for this client?