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 B
Explanation
Choice A reason: Lipid-laden mast cells are not foam cells. Mast cells are immune cells that release histamine and other inflammatory mediators. They do not accumulate lipids or have a soap-like texture.
Choice B reason: Macrophages that engulf low-density lipoproteins (LDLs) are foam cells. They are part of the atherosclerotic process that leads to plaque formation in the blood vessels. They are called foam cells because they have a foamy appearance under the microscope.
Choice C reason: Injured neutrophil clots are not foam cells. Neutrophils are immune cells that fight infection and form pus. They do not engulf LDLs or contribute to atherosclerosis.
Choice D reason: Deposited adipose cells are not foam cells. Adipose cells are fat cells that store energy and secrete hormones. They do not phagocytose LDLs or form plaques in the blood vessels.
Correct Answer is D
Explanation
Choice A reason: Jugular vein distention is a sign of right-sided heart failure, not left-sided. It indicates increased pressure in the right atrium and vena cava.
Choice B reason: Peripheral edema is also a sign of right-sided heart failure, not left-sided. It indicates fluid retention in the lower extremities and abdomen.
Choice C reason: Decreased systemic vascular resistance is not a characteristic of left-sided heart failure. It is a compensatory mechanism that occurs in response to reduced cardiac output.
Choice D reason: Pulmonary congestion is a characteristic of left-sided heart failure. It indicates fluid accumulation in the lungs due to the inability of the left ventricle to pump blood effectively.
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