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 D

Explanation

Choice A reason: Assessing for orthostatic hypotension before administering the dose is not necessary, as labetalol does not cause orthostatic hypotension. Orthostatic hypotension is a condition where the blood pressure drops significantly when changing positions from lying to sitting or standing. Labetalol is a beta-blocker that lowers blood pressure by reducing the heart rate and cardiac output.

Choice B reason: Administering the dose and monitoring the client's B/P regularly is not appropriate, as labetalol may cause further bradycardia (slow heart rate) in this client. The client's heart rate is already below normal (48 beats/minute), which may indicate that labetalol is overdosed or contraindicated. Bradycardia can lead to decreased perfusion, dizziness, fatigue, and fainting.

Choice C reason: Applying a telemetry monitor before administering the dose is not sufficient, as labetalol may cause serious cardiac arrhythmias (irregular heart rhythms) in this client. The client's heart rate is already below normal (48 beats/minute), which may indicate that labetalol is affecting the electrical conduction system of the heart. Arrhythmias can cause palpitations, chest pain, shortness of breath, and cardiac arrest.

Choice D reason: Withholding the scheduled dose and notifying the healthcare provider is the best action for the nurse to take in this situation. The client's heart rate is already below normal (48 beats/minute), which may indicate that labetalol is causing adverse effects or interactions with other medications. The healthcare provider should be informed of the client's vital signs and medication history, and decide whether to adjust or discontinue labetalol.

A. Cover your skin before going outside. B. Monitor skin for excessive bruising. C. Limit intake of high-potassium foods. D. Replace salt with a salt substitute.

Correct Answer is C

Explanation

Choice B reason:While spironolactone can sometimes cause side effects, bruising is not a typical issue associated with this medication.

Choice A reason: Covering your skin before going outside is not an instruction that the nurse should include in this client's plan of care, but rather a general precaution that anyone should take to protect their skin from sun damage. Spironolactone does not increase the risk of sunburn or photosensitivity.

Choice C reason:Spironolactone is a potassium-sparing diuretic that works by blocking aldosterone, which helps reduce fluid retention. However, because it spares potassium, there is a risk of hyperkalemia (high potassium levels). Therefore, clients taking spironolactone should limit their intake of high-potassium foods (e.g., bananas, oranges, spinach, avocados) to avoid dangerous potassium levels.

Choice D reason: Replacing salt with a salt substitute is not an instruction that the nurse should include in this client's plan of care, but rather a dangerous practice that can lead to hyperkalemia. Salt substitutes are often made with potassium chloride, which can increase the potassium level in the blood. The client should use herbs or spices instead of salt or salt substitutes to flavor their food.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

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?

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?

Prior to administering oral doses of calcitriol and calcium carbonate to a client with hypoparathyroidism, the nurse notes that the client's total calcium level is 14 mg/dL (3.5 mmol/L). Which action should the nurse implement?

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?

On admission, the healthcare provider prescribes a broad spectrum antibiotic for a client with a gram-negative infection. Before administering the first dose, it is most important for the nurse to implement which prescription?

A client with anemia secondary to chronic kidney disease (CKD) started a prescription for epoetin alfa two months ago. Which client finding best indicates that the medication is effective? Hemoglobin (Hgb) [Reference Range: Male: 14 to 18 g/dL (8.7 to 11.2 mmol/L)]