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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. The body builds up a tolerance of melatonin, requiring higher doses to get therapeutic benefits. B. Tell the daughter to check with the healthcare provider before providing herbal supplements, C. Remind the daughter that all herbal supplements will not be helpful given the condition of the client. D. Remind the client that herbal medications are not regulated by the Food and Drug Administration. E. Explain that melatonin can interfere with the action of prescribed medications for DM and HF.

Correct Answer is ["B","D","E"]

Explanation

A. The body builds up a tolerance of melatonin, requiring higher doses to get therapeutic benefits: Tolerance to melatonin is not a typical phenomenon. Melatonin acts on circadian rhythms rather than through receptor pathways that lead to tolerance, so increasing doses over time is not standard or necessary for effectiveness.

B. Tell the daughter to check with the healthcare provider before providing herbal supplements: It is essential to involve the healthcare provider before starting any herbal supplement, especially for clients with complex conditions like diabetes and heart failure, to prevent interactions or exacerbations of existing diseases.

C. Remind the daughter that all herbal supplements will not be helpful given the condition of the client: While some herbal supplements may be inappropriate, it is not accurate to state that all herbal remedies are unhelpful. Each supplement must be evaluated individually based on the client’s medical conditions and medications.

D. Remind the client that herbal medications are not regulated by the Food and Drug Administration: Herbal products like melatonin are classified as dietary supplements and are not strictly regulated by the FDA for quality, consistency, or efficacy, posing a risk for variability in potency and purity.

E. Explain that melatonin can interfere with the action of prescribed medications for DM and HF: Melatonin has the potential to interfere with glycemic control and may also influence blood pressure regulation, complicating the management of diabetes and heart failure. This interaction risk should be discussed with the client.

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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

An older client who has type 2 diabetes mellitus (DM) and a history of heart failure (HF) tells the home health nurse that his daughter brought him melatonin to help with sleeping problems. Which information should the nurse provide to the client? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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

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