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.)

A) Low-back pain:
Low-back pain is not typically associated with transfusion reactions. While certain complications of blood transfusions, such as transfusion-related acute lung injury (TRALI) or hemolytic reactions, can cause back pain, diphenhydramine is not specifically administered to prevent this manifestation.

B) Fever:
Fever can be a manifestation of various transfusion reactions, including febrile non-hemolytic reactions or bacterial contamination of blood products. However, diphenhydramine is not typically administered to prevent fever associated with transfusion reactions. Instead, measures such as leukoreduction of blood products or premedication with acetaminophen may be used to reduce the risk of febrile reactions.

C) Dyspnea:
Dyspnea, or difficulty breathing, can occur in severe transfusion reactions such as transfusion-related acute lung injury (TRALI) or anaphylaxis. While diphenhydramine may be part of the treatment for anaphylaxis, it is not specifically administered to prevent dyspnea associated with transfusion reactions.

D) Urticaria.
Urticaria, commonly known as hives, is a common manifestation of an allergic transfusion reaction. Diphenhydramine is an antihistamine medication that can help prevent or alleviate allergic reactions, including urticaria, by blocking the action of histamine, a substance released during allergic reactions. Administering diphenhydramine before a blood transfusion is a preventive measure to reduce the risk of allergic transfusion reactions, including urticaria.

A) Respirations rate:
Respiratory rate is an important vital sign to monitor in patients with shock, as respiratory distress can indicate inadequate oxygenation. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.

B) Heart rate:
Heart rate is an important vital sign to monitor in patients with shock, as tachycardia (rapid heart rate) may indicate the body's compensatory response to maintain cardiac output and tissue perfusion. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.

C) Blood pressure.
In shock, the body's vital organs are not receiving adequate blood flow and oxygen, leading to a life-threatening condition. While all vital signs are important to monitor in a patient experiencing shock, blood pressure is typically considered the most critical because it reflects the perfusion pressure—the force driving blood through the circulatory system to deliver oxygen and nutrients to the body's tissues. A decrease in blood pressure can indicate inadequate tissue perfusion and impending organ failure. Therefore, timely assessment and monitoring of blood pressure are essential for identifying and managing shock effectively.

D) Temperature:
Temperature monitoring is important in assessing for signs of infection or other systemic issues that may contribute to shock, such as sepsis. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.