An albuterol inhaler is prescribed for a client with allergic asthma.

The nurse reinforces instructions regarding the adverse effects of this medication.

Which adverse effect is associated with this medication?

Choice A rationale

Assessment is always the initial step in the nursing process to establish a baseline. Auscultating the lung fields allows the nurse to identify the specific areas of congestion, atelectasis, or accumulation of secretions. This data is essential to determine which lobes require postural drainage and to evaluate the effectiveness of the treatment afterward. Physical assessment ensures that the intervention is targeted appropriately to the client's current physiological respiratory status and needs.

Choice B rationale

Percussion involves using cupped hands to create air pockets that vibrate the chest wall. While this mechanical action helps loosen thick secretions from the bronchial walls, it must only be performed after a thorough assessment and proper positioning. Starting this before auscultation would be premature as the nurse would not have confirmed the specific location of the mucus plugs. Vibration and percussion are active treatment phases that follow the initial diagnostic assessment and positioning steps.

Choice C rationale

Mouth care is an important comfort measure, especially after postural drainage, because the client may expectorate foul-smelling or bad-tasting sputum. However, providing oral hygiene does not take priority over the clinical assessment or the physical mobilization of secretions. It is generally considered a post-procedure intervention to promote hygiene and patient comfort. Prioritizing mouth care first would delay the necessary therapeutic clearing of the airway in a client with active pneumonia and congestion.

Choice D rationale

Postural drainage uses gravity to facilitate the movement of secretions from peripheral airways into the central nodes for expectoration. While positioning the affected lung area above the trachea is a core component of the procedure, it must be guided by the findings of the lung auscultation. The nurse cannot correctly position the client without first knowing which specific lung segments are involved. Therefore, positioning is the second logical step after the initial respiratory assessment is complete.

Choice A rationale

If a person is able to run from the room, it indicates that they still have some level of functional consciousness and physical coordination. While the person may be in distress or panicking, the act of running suggests that their airway is not yet completely obstructed to the point of immediate collapse. However, the nurse should still follow the individual to ensure they do not lose consciousness in a private area where help is unavailable.

Choice B rationale

Waving hands and experiencing tachypnea, which is a respiratory rate typically greater than 20 breaths per minute, suggests that the individual is still moving air in and out of the lungs. Although the person is clearly distressed and may have a partial airway obstruction, the presence of rapid breathing means oxygen is still reaching the alveoli. The nurse should monitor them closely and encourage them to cough forcefully to dislodge any potential foreign body.

Choice C rationale

Vigorous coughing is a highly positive sign that the airway is only partially obstructed. A forceful cough indicates that the individual can generate enough subglottic pressure to attempt to expel the object. Scientific protocols for choking state that as long as the person is coughing or speaking, the nurse should not perform the Heimlich maneuver, as external pressure could inadvertently push the object deeper into the trachea, causing a total and fatal obstruction.

Choice D rationale

The universal sign for choking is when a person clutches their throat with one or both hands. If they are also unable to speak, cry, or breathe, it signifies a total upper airway obstruction. In this state, no air is passing through the vocal cords, making sound production impossible. This is a life-threatening emergency requiring immediate intervention with abdominal thrusts to create an artificial cough and force the object out using the residual air.