After receiving an albuterol nebulizer, a client complains of feeling anxious and shaky. Which response by the nurse is best?

"The next scheduled nebulizer treatment will be skipped."

"This is an expected side effect, but let me take your pulse."

"I will hold the respiratory medication for 24 hours."

"I will request medication for anxiety from the healthcare provider."

Answer and Explanation

The Correct Answer is B

A. "The next scheduled nebulizer treatment will be skipped.": Skipping the next treatment without evaluation may compromise airway management. Albuterol is essential for bronchodilation, and withholding it could worsen respiratory distress.

B. "This is an expected side effect, but let me take your pulse.": Anxiety and tremors are common side effects of albuterol due to its beta-adrenergic stimulation. Monitoring the pulse is appropriate since tachycardia is a possible adverse effect requiring close observation.

C. "I will hold the respiratory medication for 24 hours.": Holding albuterol for 24 hours is unsafe, as the client may experience worsening bronchospasm or hypoxemia. Adjustments should only be made with provider guidance, not independently by the nurse.

D. "I will request medication for anxiety from the healthcare provider.": Anxiety in this context is a medication side effect, not a psychiatric condition. Treating it with additional medication is unnecessary when monitoring and reassurance are more appropriate.

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Correct Answer is A

Explanation

Rationale:

A. Placing the client in airborne isolation: The client’s symptoms strongly suggest pulmonary tuberculosis. Airborne isolation prevents transmission of Mycobacterium tuberculosis to healthcare workers and other clients, making infection control the first concern.

B. Obtaining sputum cultures: Sputum cultures are necessary to confirm TB diagnosis and guide treatment. However, cultures should be obtained only after the client has been placed in proper isolation to prevent potential spread of infection during the collection process.

C. Monitoring the client's fluid intake and output: While hydration status is important in clients with fever, weight loss, and decreased appetite, it is not an immediate priority compared to preventing transmission of a highly contagious airborne disease.

D. Assessing the client's temperature every 8 hours: Monitoring fever helps track infection severity but does not address the urgent risk of spreading TB. Infection control measures take precedence before routine monitoring can be performed.

A. "My energy level will increase over time." B. "I need to avoid prolonged sun exposure." C. "My medications will ultimately correct my problem" D. "I do not need to make changes in my diet."

Correct Answer is B

Explanation

A. "My energy level will increase over time.": Fatigue is one of the most common and persistent symptoms of systemic lupus erythematosus (SLE). Energy levels often fluctuate depending on disease activity, and clients may experience chronic fatigue rather than steady improvement.

B. "I need to avoid prolonged sun exposure.": Ultraviolet (UV) light can trigger lupus flares and worsen symptoms such as skin rashes, joint pain, and fatigue. Avoiding prolonged sun exposure and using sun protection is a key self-care measure in SLE.

C. "My medications will ultimately correct my problem.": Medications such as corticosteroids, immunosuppressants, and NSAIDs help control inflammation and manage symptoms, but they do not cure SLE. The disease is chronic and requires ongoing management rather than correction.

D. "I do not need to make changes in my diet.": While no specific diet cures lupus, a balanced diet rich in vitamins, minerals, and anti-inflammatory foods supports overall health. Dietary modifications may also help manage side effects of medications, so disregarding nutrition is not accurate.

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After receiving an albuterol nebulizer, a client complains of feeling anxious and shaky. Which response by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is teaching the client newly diagnosed with systemic lupus erythematous about the condition. Which statement by the client indicates teaching was effective?

Correct Answer is B

Explanation

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