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Patient Data

Click to specify which aspects of the 0930 focused assessment indicate adverse reactions to albuterol.

0930: Albuterol given as prescribed via nebulizer. Following the treatment, decreased wheezes noted. The client's hands are trembling and is reporting a headache. Heart rate 129 beats/minute, respirations 20 breaths/minute, blood pressure 125/72 mm Hg, oxygen saturation 99% on room air.

The client's hands are trembling

is reporting a headache

Heart rate 129 beats/minute

respirations 20 breaths/minute

blood pressure 125/72 mm Hg

oxygen saturation 99% on room air

Answer and Explanation

The Correct Answer is ["A","B","C"]

Trembling: Trembling is a known side effect of albuterol due to its beta-2 adrenergic stimulation. Albuterol can cause fine muscle tremors, particularly in the hands, as part of its systemic sympathomimetic effects following inhalation.
Headache: Headache can result from vasodilation and mild CNS stimulation caused by beta-agonists like albuterol. It is a frequently reported side effect and can occur even with appropriate dosing, particularly in sensitive individuals.
Heart rate 129 beats/minute: Tachycardia is a common adverse effect of albuterol because it stimulates beta-1 receptors at higher doses, leading to an increased heart rate. A heart rate of 129 beats/minute post-treatment indicates a significant sympathetic response.
Respirations 20 breaths/minute: A decrease in respiratory rate from 36 to 20 breaths/minute reflects clinical improvement in respiratory distress. It is a positive response to albuterol therapy, not an adverse reaction.
Oxygen saturation 99% on room air: Improvement of oxygen saturation from 83% to 99% is a therapeutic goal with bronchodilator use. This indicates better gas exchange after albuterol treatment and is not an adverse reaction.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Document the assessment findings in the electronic health record: Riluzole is not curative for ALS; it only modestly slows disease progression. Continuing muscle weakness and atrophy are expected findings in ALS, even after starting treatment. Accurate documentation is appropriate because no immediate change in therapy is indicated based solely on these observations.

B. Explain that the medication takes several weeks to reverse symptoms: Riluzole does not reverse ALS symptoms. It may slightly prolong survival by slowing the progression of muscle weakness, but it does not regenerate lost function or reverse disease-related damage.

C. Advise the client to schedule an appointment for liver function tests: Riluzole can affect liver function and periodic monitoring is important, but muscle weakness alone does not directly signal liver problems. Unless there are signs of hepatotoxicity, there is no immediate need for unscheduled testing.

D. Withhold the medication until the healthcare provider is notified: There is no indication to withhold riluzole based on ongoing muscle weakness, as this is consistent with the natural course of ALS. Interrupting therapy without a clear medical reason could harm the client.

A. Take the medication during pregnancy. B. Use folic acid to protect the liver. C. Store the medication at room temperature. D. Obtain a platelet count weekly.

Correct Answer is A

Explanation

A. Take the medication during pregnancy: Methotrexate is highly teratogenic and absolutely contraindicated during pregnancy because it can cause severe fetal malformations or death. Clients must be instructed to avoid pregnancy while on methotrexate and for some time after discontinuing the drug, making this a critical point requiring immediate correction.

B. Use folic acid to protect the liver: Methotrexate interferes with folate metabolism, and folic acid supplementation is recommended to reduce some side effects such as liver toxicity, mucositis, and bone marrow suppression. This statement reflects appropriate understanding of supportive care during methotrexate therapy.

C. Store the medication at room temperature: Methotrexate should be stored at room temperature away from light and moisture, consistent with safe medication handling practices. This information is accurate and does not require additional instruction.

D. Obtain a platelet count weekly: Methotrexate can cause bone marrow suppression, increasing the risk of thrombocytopenia. Regular monitoring of blood counts, including platelets, is standard practice to detect toxicity early, so this action is appropriate and understood correctly.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with amyotrophic lateral sclerosis (ALS) has been taking riluzole for two weeks. The nurse notes that the client remains weak with observable muscle atrophy. Which action should the nurse take?

Correct Answer is A

Explanation

A client receives a prescription for methotrexate. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is A

Explanation

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