An adult patient is admitted for an asthma attack. Which assessment obtained by the nurse would support that beta2 adrenergic agonist albuterol was effective?
Decrease in wheezing present on auscultation
Respiratory rate increased to 38 breaths/min
Sputum production is clear and watery
Use of neck muscles
The Correct Answer is A
Choice A reason: Decrease in wheezing present on auscultation indicates that albuterol was effective. Albuterol is a bronchodilator that relaxes the smooth muscles of the airways and reduces the airway resistance. This improves the airflow and reduces the wheezing sound that is caused by the turbulent flow of air through the narrowed airways.
Choice B reason: Respiratory rate increased to 38 breaths/min does not indicate that albuterol was effective. It indicates that the patient is still experiencing respiratory distress and hypoxia. The normal respiratory rate for adults is 12 to 20 breaths/min. A high respiratory rate can also be a side effect of albuterol, as it can stimulate the sympathetic nervous system and increase the heart rate and blood pressure.
Choice C reason: Sputum production is clear and watery does not indicate that albuterol was effective. It indicates that the patient has a productive cough and is expelling mucus from the lungs. Sputum production is not directly affected by albuterol, as it does not have anti-inflammatory or mucolytic properties.
Choice D reason: Use of neck muscles does not indicate that albuterol was effective. It indicates that the patient is using accessory muscles to breathe and is exerting more effort to inhale. This is a sign of severe respiratory distress and airway obstruction. Albuterol should relieve the bronchospasm and reduce the need for accessory muscle use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct instruction by the nurse. Nausea and vomiting are signs of digoxin toxicity, which can be life-threatening. The patient should report these symptoms to their health care provider as soon as possible and have their digoxin level checked.
Choice B reason: This is not a correct instruction by the nurse. Auditory hallucinations are not common adverse effects of digoxin. They are more likely to occur with other drugs, such as antipsychotics or opioids.
Choice C reason: This is not a correct instruction by the nurse. Decreasing the amount of high-potassium foods can increase the risk of digoxin toxicity, as potassium competes with digoxin for binding sites on the cardiac cells. The patient should maintain a normal potassium intake and avoid sudden changes in their diet.
Choice D reason: This is not a correct instruction by the nurse. Omitting the dose of digoxin if the pulse is 70 can lead to underdosing and ineffective treatment of heart failure. The patient should only omit the dose of digoxin if their pulse is below 60, as this indicates bradycardia, which is another sign of digoxin toxicity.
Correct Answer is B
Explanation
Choice A reason: Respiratory acidosis does not cause no change in affinity of hemoglobin with oxygen. It causes a decrease in affinity of hemoglobin with oxygen, which means that hemoglobin releases more oxygen to the tissues. This is known as the Bohr effect, which is a physiological response to low pH and high CO2 levels.
Choice B reason: Respiratory acidosis causes a decrease in affinity of hemoglobin with oxygen, which means that hemoglobin releases more oxygen to the tissues. This is the correct statement that describes the expected finding in this patient. The decrease in affinity of hemoglobin with oxygen is a compensatory mechanism that tries to restore the oxygen balance in the body.
Choice C reason: Respiratory acidosis does not cause an increase in affinity of hemoglobin with oxygen. It causes a decrease in affinity of hemoglobin with oxygen, which means that hemoglobin releases more oxygen to the tissues. An increase in affinity of hemoglobin with oxygen would mean that hemoglobin holds on to oxygen more tightly, which would worsen the hypoxia in the patient.
Choice D reason: Respiratory acidosis does not cause a decrease in blood CO2. It causes an increase in blood CO2, which is the primary cause of the low pH. A decrease in blood CO2 would indicate respiratory alkalosis, which is a condition of high pH and low CO2 levels.
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