During the administration of albuterol per nebulizer, the client reports shakiness. The client's vital signs are heart rate 120 beats/minutes, respirations 20 breaths/minute, blood pressure 140/88 mm Hg. Which action should the nurse take?

Educate client about the side effects of albuterol.

Administer an anxiolytic.

Obtain 12 lead electrocardiogram.

Stop the albuterol administration and restart in 30 minutes.

Answer and Explanation

The Correct Answer is A

A. This is the most appropriate action. Shakiness (tremor), tachycardia, and mild increases in blood pressure are common, expected side effects of albuterol, a beta-2 agonist. These effects usually resolve on their own and are not typically dangerous in otherwise stable clients. The nurse should provide reassurance and education, explaining that these symptoms are temporary and expected, while monitoring the client for more severe reactions.

B. Anxiolytics are unnecessary in this situation. The client’s symptoms are pharmacologic side effects of the medication, not anxiety. Administering an anxiolytic could mask symptoms and cause unnecessary sedation.

C. While tachycardia can sometimes warrant monitoring in clients with cardiac disease, in a client without known cardiac complications, the mild tachycardia from albuterol is usually benign and does not require immediate ECG assessment.

D. Stopping treatment is unnecessary unless the client develops severe adverse effects, such as significant chest pain, arrhythmia, or extreme shortness of breath. Interruption could compromise respiratory treatment for bronchospasm or asthma exacerbation.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This is the most important assessment because thrombocytopenia indicates a low platelet count, which significantly increases the risk of bleeding. After a bone marrow biopsy, the site can bleed internally or externally. Frequent monitoring of the aspiration site for signs of bleeding, hematoma formation, or excessive oozing is essential to prevent complications. Immediate intervention can be provided if bleeding is detected.

B. Monitoring skin elasticity primarily assesses hydration status. While important in overall patient care, it is not directly related to bleeding risk or complications from a bone marrow biopsy, especially in a thrombocytopenic patient.

C. Measuring urinary output is crucial for assessing kidney function and fluid balance but does not provide direct information about post-procedure bleeding risk in a patient with thrombocytopenia.

D. Assessing body temperature is important for detecting infection, particularly in immunocompromised patients such as those with leukemia. However, while infection prevention is important, it is not the most immediate concern after a procedure where bleeding is the primary risk due to low platelet count.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

Hypoxia: The child is at risk for hypoxia because pneumonia causes impaired gas exchange in the lungs. Consolidation in the lower lobes reduces oxygen diffusion into the bloodstream, increasing the risk of inadequate oxygenation.
Lower lobe consolidation and decreased breath sounds: The chest x-ray shows areas of consolidation in the lower lobes, and auscultation reveals decreased breath sounds in these areas. These findings directly contribute to impaired oxygenation and the risk of hypoxia.

Rationale for incorrect choices:

Malnutrition: There is no evidence of poor intake, weight loss, or nutritional deficiency. The acute concern is respiratory compromise, not nutritional status.
Hyperthermia: The child has a mild fever (102.8° F), but hyperthermia refers to dangerously high temperatures, typically >104° F. Fever alone does not indicate immediate hyperthermia risk.
History of seasonal allergies and mild asthma: While these conditions may predispose to respiratory infections, they are not the immediate cause of hypoxia. The consolidation and decreased breath sounds are the direct physiological cause.
Hypotonic extremities and fissured tongue: These are signs of Down syndrome and mild dehydration or chronic hypotonia, but they are not the primary cause of hypoxia in this scenario.

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During the administration of albuterol per nebulizer, the client reports shakiness. The client's vital signs are heart rate 120 beats/minutes, respirations 20 breaths/minute, blood pressure 140/88 mm Hg. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Correct Answer is A

Explanation

The child is admitted to the pediatric unit. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The client is at risk for dropdowndue todropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

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Drag from Word Choices to complete the sentence. The nurse knows that, if left untreated, the client's condition could progress to developingdropdown,dropdownanddropdown

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