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 D

Explanation

A. While biliary duct obstruction can cause abdominal pain, vomiting, and fever, it would typically present with jaundice, which is not mentioned in the scenario.
B. Surgical site infections can cause pain, fever, and elevated white blood cell count, but they would not typically present with vomiting or elevated serum amylase and lipase.
C. Hepatorenal failure would present with elevated liver enzymes, decreased urine output, and other signs of renal dysfunction, which are not mentioned in the scenario.
D. The client's presentation of persistent upper abdominal pain, vomiting, fever, and elevated serum amylase and lipase is consistent with acute pancreatitis. This condition occurs when pancreatic enzymes become activated within the pancreas itself, causing inflammation and tissue damage.

A. Hyperventilation is eliminating carbon dioxide rapidly. B. High levels of carbon dioxide have accumulated in the blood. C. Carbon dioxide is converted in the kidneys for elimination. D. Blood oxygen levels are stimulating the respiratory rate.

Correct Answer is B

Explanation

A. This statement describes a situation that leads to respiratory alkalosis, not respiratory acidosis.
Hyperventilation causes an excessive elimination of CO₂, resulting in decreased levels of carbonic acid in the blood and an increased pH (alkalosis). Therefore, this option does not support respiratory acidosis.
B. This statement directly supports the condition of respiratory acidosis. In respiratory acidosis, CO₂ is not being adequately removed from the body, leading to increased levels in the blood (hypercapnia). This accumulation raises the concentration of carbonic acid, thereby lowering the blood pH and causing acidosis.
C. While the kidneys do play a role in the long-term regulation of acid-base balance, they do not directly eliminate CO₂. Instead, they manage bicarbonate (HCO₃⁻) levels and can retain or excrete bicarbonate in response to acidosis or alkalosis. However, this process is more related to metabolic compensation rather than the immediate cause of respiratory acidosis itself.
D. While low blood oxygen levels (hypoxemia) can stimulate the respiratory rate as a compensatory mechanism, this does not directly support the pathophysiology of respiratory acidosis. In respiratory acidosis, the primary issue is the retention of CO₂, not an increase in the respiratory rate due to low oxygen.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

Correct Answer is B

Explanation

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