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 C

Explanation

A. While some individuals with Crohn's disease may experience diarrhea and need to maintain hydration, restricting fluids is not a primary dietary limitation. Instead, dietary modifications typically focus on specific foods rather than fluid intake.
B. This advice is generally not appropriate. Foods high in calcium and iron are usually encouraged, especially since individuals with Crohn's disease can be at risk for deficiencies due to malabsorption and potential blood loss from inflammation. Limiting these nutrients could lead to further health issues.
C. This is a relevant and effective approach. An elimination diet can help identify specific foods that may trigger or worsen symptoms in individuals with Crohn's disease. It involves removing suspected trigger foods from the diet and then gradually reintroducing them to observe any reactions. This strategy can help tailor dietary recommendations based on individual tolerance.
D. While some individuals with gastrointestinal conditions may have gluten sensitivity or celiac disease, avoiding gluten is not a universal recommendation for all patients with Crohn's disease. Many people with Crohn's do not need to avoid gluten unless they have a specific intolerance or sensitivity. Blanket advice to avoid gluten may not be necessary.

A. Obtain a pulse oximetry reading. B. Coach through using huff coughing. C. Provide nebulizer breathing treatment. D. Attach humidification to oxygen delivery.

Correct Answer is A

Explanation

A. Pulse oximetry measures the oxygen saturation in the blood. A low reading indicates that the client's body is not getting enough oxygen, which can be a serious problem.
B. Huff coughing can help clear mucus from the lungs, but it may not be effective if the client is severely short of breath.
C. Nebulizer breathing treatment can help open up the airways and improve breathing, but it may not be necessary if the client's oxygen saturation is high.
D. Attaching humidification to oxygen delivery can help moisten the airways and prevent them from drying out. However, it is not a priority intervention if the client is experiencing acute dyspnea and tachypnea.

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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

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

Correct Answer is C

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?

Correct Answer is A

Explanation

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