A client with emphysema is reporting a difficulty in breathing and exhibiting an audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

Uncontrollable shaking.

Increased anxiety.

Irregular rapid heart rate.

Throat irritation.

Answer and Explanation

The Correct Answer is C

A.   This could indicate tremors, which are a common side effect of albuterol due to its action as a beta-2 agonist. While it can be uncomfortable for the client, it is generally not life-threatening and can be monitored unless it severely affects the client’s ability to function.
B.   Increased anxiety can occur due to hypoxia, difficulty breathing, or as a side effect of albuterol. While concerning, it does not typically require immediate intervention unless it leads to further complications or severe distress.
C.   Albuterol can cause tachycardia (rapid heart rate) and arrhythmias as side effects, particularly with frequent use. An irregular rapid heart rate can be indicative of significant cardiac distress and may lead to serious complications. This finding warrants immediate intervention as it poses a risk to the client’s safety and may indicate potential worsening of the condition or an adverse reaction to the medication.
D.   Throat irritation can occur with inhaled medications and, while uncomfortable, it is generally not an urgent concern. It does not require immediate intervention unless it leads to significant complications like severe swelling or difficulty swallowing.

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Correct Answer is B

Explanation

A. While nodules (such as rheumatoid nodules) can occur in RA, they typically develop later in the disease. Early signs are more often related to the small joints. Additionally, the presence of nodules is not necessarily indicative of early RA.
B. Early signs of rheumatoid arthritis often manifest in the small joints of the hands and fingers. The nurse should look for swelling, tenderness, or deformities in these areas, as these can indicate inflammation and damage characteristic of RA.
C. Skin lesions are not a typical early sign of rheumatoid arthritis. While some skin manifestations can occur, they are not considered primary indicators of the disease. The focus should be on joint assessment, especially in the hands and feet.
D. Lymphadenopathy can occur in various conditions, but it is not a key assessment for early rheumatoid arthritis. RA primarily affects joints and does not typically present with significant lymph node enlargement.

A. Count the apical and radial pulses simultaneously. B. Measure the client's capillary glucose level. C. Observe for edema around the ankles. D. Auscultate the client's bowel sounds.

Correct Answer is D

Explanation

A. While assessing heart rate is important, it is less critical in this context compared to monitoring bowel function. Opioids can cause respiratory depression, but they do not commonly lead to changes in heart rate that would necessitate immediate assessment unless other symptoms are present.
B. Measuring blood glucose is typically relevant for clients with diabetes or those at risk for hyperglycemia or hypoglycemia. It is not directly related to the use of hydromorphone and does not address the primary concerns associated with opioid therapy.
C. While peripheral edema can occur in some clients, especially those with fluid overload or heart failure, it is not a primary concern related to hydromorphone administration. This assessment is less relevant in the context of opioid side effects.
D. Hydromorphone is an opioid analgesic, which can significantly slow down gastrointestinal motility, leading to constipation and decreased bowel sounds. Monitoring bowel sounds is crucial to identify any potential gastrointestinal complications, such as ileus or severe constipation, which can occur with prolonged opioid use.

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A client with emphysema is reporting a difficulty in breathing and exhibiting an audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

Correct Answer is B

Explanation

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Correct Answer is D

Explanation

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

An adult client is admitted with AIDS and oral Candida albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection. Prior to administering the H. pylori treatment regimen, the nurse should review the electronic medical record for which medication?

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety and a hoarse voice. Which nursing problem is the priority for this client?