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 this is a good suggestion for managing duodenal ulcers, it doesn't directly address the issue of dairy products. Dairy products, especially milk and cream, can stimulate gastric acid secretion and worsen duodenal ulcer symptoms.
B. The nurse should clarify that while dairy products may seem beneficial, they can actually exacerbate duodenal ulcers. The client should be advised to avoid or limit foods rich in milk and cream.
C. While caffeine can irritate the stomach and worsen ulcer symptoms, this is not the most important point to address in this situation. The primary concern is the client's belief that dairy products will help protect the ulcer, which is incorrect.
D. This would be counterproductive. The nurse should be discouraging the client from consuming dairy products, not encouraging them.

A. Offer a prescribed PRN analgesic. B. Obtain arterial blood gases. C. Administer a prescribed antipyretic. D. Suction to clear secretions from airway.

Correct Answer is D

Explanation

A. While managing pain can improve comfort and potentially aid in better respiratory effort, it is not the most urgent intervention given the client's respiratory distress and weak cough. Pain relief is important, but it does not directly address the immediate airway clearance needs or the client’s respiratory status.
B. While obtaining arterial blood gases (ABGs) can provide valuable information about the client’s oxygenation and acid-base status, it is not the most immediate intervention. The client’s oxygen saturation is relatively stable at 94%, so while this test is important, addressing airway clearance would take precedence over obtaining ABGs in this context.
C. Administering an antipyretic can help reduce the client's fever and improve comfort. However, similar to the analgesic, this intervention does not directly address the respiratory distress or the need to clear secretions. It may be a necessary intervention, but it is not the highest priority given the current respiratory status.
D. This is the most critical intervention. The client's congested breath sounds and weak cough suggest that there are secretions in the airway that may be obstructing airflow. Suctioning to clear these
secretions will help improve the client’s airway patency, facilitate better gas exchange, and alleviate
respiratory distress.

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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

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow up action by the nurse?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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