An adult patient presents to the emergency department with complaints of shortness of breath and increased work of breathing.
Assessment
The patient is alert and oriented times 3, skin is pink, warm and dry. BP 148/88, T98, P92. R 24, pulse oximetry 91% on room air. Assessment of the lung reveals expiratory wheezing throughout the lung fields.
The physician orders an albuterol nebulizer. What assessments should the nurse plan to complete after administering the albuterol?
(Select All that Apply.)
Respiratory rate and pulse
Pulse oximetry
Capillary refill
Glucose
Lung sounds
Correct Answer : A,B,E
A. Respiratory rate and pulse: Albuterol is a bronchodilator medication commonly used to relieve bronchospasm in conditions like asthma and chronic obstructive pulmonary disease (COPD). Monitoring the patient's respiratory rate and pulse is essential to assess the response to the medication and any potential adverse effects.
B. Pulse oximetry: Albuterol helps to open the airways and improve oxygenation in patients with bronchospasm. Monitoring oxygen saturation using pulse oximetry provides valuable information about the patient's respiratory status and response to treatment.
C. Capillary refill: Capillary refill is typically assessed to evaluate peripheral perfusion and circulation. While it is an important assessment in certain clinical situations, it is not directly related to monitoring the response to albuterol administration.
D. Glucose: Glucose monitoring is not typically indicated after administering albuterol nebulizer unless the patient has a history of diabetes or there are specific concerns regarding glucose levels.
E. Lung sounds: Assessing lung sounds before and after administering albuterol helps to evaluate the effectiveness of the medication in relieving bronchospasm. Improvement in lung sounds, such as decreased wheezing or clearer breath sounds, indicates a positive response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
To administer the correct dose of amoxicillin, the nurse needs to calculate the volume of suspension that contains the prescribed dose of 500 mg.
Since the available suspension has a concentration of 250 mg per 5 ml, the nurse can calculate the required volume using the formula: (prescribed dose/concentration) x volume of concentration = required volume.
Plugging in the numbers: (500 mg / 250 mg) x 5 ml = 2 x 5 ml = 10 ml.
Therefore, the nurse should administer 10 ml of the amoxicillin suspension to deliver a dose of 500 mg.
Correct Answer is C
Explanation
To calculate the rate of administration in milliliters per hour (mL/hr):
First, find the total volume to be infused: 1000 mL
Next, divide the total volume by the total time in hours: 1000 mL ÷ 5 hours = 200 mL/hr
Therefore, you will administer the solution at a rate of 200 mL/hr.
To calculate the rate of administration in drops per minute (drops/min):
First, find the total drops: 1000 mL × 15 drops/mL = 15,000 drops
Next, divide the total drops by the total time in minutes: 15,000 drops ÷ (5 hours × 60 minutes/hour) = 50 drops/min
Therefore, you will administer the solution at a rate of 200 mL/hr and 50 drops/min.
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