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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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.

A. Perform a bladder scan. B. Assess urine output. C. Monitor blood pressure. D. Obtain daily weights.

Correct Answer is C

Explanation

Choice A reason: A bladder scan is used to measure the post-void residual urine volume, which can indicate urinary retention. It is not related to the adverse effects of tamsulosin.

Choice B reason: Assessing urine output is important for clients with urinary problems, but it is not specific to the adverse effects of tamsulosin.

Choice C reason: Tamsulosin is an alpha-blocker that relaxes the smooth muscles of the prostate and bladder neck, improving urine flow. However, it can also cause hypotension, dizziness, and fainting as adverse effects. Therefore, monitoring blood pressure is essential for clients taking tamsulosin.

Choice D reason: Obtaining daily weights is not relevant to the adverse effects of tamsulosin. It is more useful for clients with fluid retention or edema.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 client with benign prostatic hyperplasia receives a new prescription of tamsulosin. Which intervention should the nurse perform to monitor for an adverse reaction?

Correct Answer is C

Explanation

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?

A female client who is a vegetarian has a new prescription for warfarin. The client states she eats leafy green vegetables every day. How should the nurse respond?

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this client's plan of care?

A client receives a new prescription for levothyroxine. Which statement made by client indicates to the nurse that education was effective?

The nurse is caring for a client who has been taking ibuprofen. Which finding is most important for the nurse to report to the healthcare provider?

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?

The nurse is preparing a discharge teaching plan for a client who is taking ciprofloxacin hydrochloride tablets, which were prescribed because of a suspected anthrax exposure. Which instruction(s) should be included in the teaching plan? (Select all that apply.)