A client with emphysema is reporting difficulty breathing and exhibiting 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?

Throat irritation

Uncontrollable shaking

Irregular rapid heart rate

Increased anxiety

Answer and Explanation

The Correct Answer is C

Choice A reason: Throat irritation is a common albuterol side effect due to its deposition in the oropharynx during inhalation. It is not life-threatening and can be managed with rinsing or spacer use. This does not require immediate intervention compared to cardiovascular effects, as it does not compromise vital organ function.

Choice B reason: Uncontrollable shaking (tremors) is a frequent albuterol side effect, resulting from beta-2 receptor stimulation in skeletal muscles. It is usually transient and benign, not requiring immediate intervention. Monitoring is sufficient unless severe, as it does not pose an acute threat compared to cardiac irregularities.

Choice C reason: An irregular rapid heart rate (tachycardia or arrhythmia) is a serious albuterol side effect, as beta-2 agonists can stimulate beta-1 receptors in the heart, causing cardiovascular instability. This warrants immediate intervention, as it risks cardiac compromise, especially in emphysema patients with compromised respiratory and cardiac reserves.

Choice D reason: Increased anxiety is a possible albuterol side effect due to its stimulatory effects on the central nervous system. While distressing, it is not immediately life-threatening. It requires monitoring but is secondary to cardiovascular complications, which pose a greater acute risk in emphysema patients with wheezing.

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Correct Answer is A

Explanation

Choice A reason: Reducing dietary sodium lowers blood pressure in hypertension by decreasing vascular fluid volume and vasoconstriction. Sodium restriction (e.g., <2.3 g/day) reduces cardiac workload, preventing complications like heart failure, making it the priority lifestyle modification for effective blood pressure control.

Choice B reason: Increasing saturated fat consumption worsens hypertension by promoting atherosclerosis and vascular stiffness. Sodium reduction is critical, as it directly lowers blood volume and pressure, reducing cardiovascular risk, making it the priority over dietary fat adjustments in hypertension management.

Choice C reason: Limiting physical activity is incorrect, as exercise lowers blood pressure by improving vascular elasticity. Sodium reduction is the priority, as it directly reduces fluid retention and vasoconstriction, providing immediate blood pressure control, making it essential for hypertension management.

Choice D reason: Smoking cessation is beneficial but not the primary focus unless active smoking is confirmed. Sodium reduction directly lowers blood pressure by decreasing fluid volume, making it the priority lifestyle change, as it addresses hypertension’s core mechanism more effectively.

A. Neutropenia B. Hypertension C. Hyperkalemia D. Weight gain

Correct Answer is A

Explanation

Choice A reason: Neutropenia, a low neutrophil count, is a common chemotherapy side effect due to bone marrow suppression, increasing infection risk. Monitoring neutrophil counts is critical, as infections in breast cancer patients can be life-threatening, making it the priority side effect to assess.

Choice B reason: Hypertension is not a typical chemotherapy side effect, though some agents cause cardiovascular effects. Neutropenia is more common, compromising immunity, making it the priority to monitor, as infections pose an immediate threat in breast cancer patients on chemotherapy.

Choice C reason: Hyperkalemia is rare with chemotherapy, except in tumor lysis syndrome. Neutropenia is a frequent side effect, increasing infection risk due to marrow suppression, making it the priority to monitor, as it directly impacts patient safety during breast cancer treatment.

Choice D reason: Weight gain is not a primary chemotherapy side effect; weight loss is more common due to nausea. Neutropenia is critical to monitor, as low neutrophils increase infection risk, requiring urgent intervention in breast cancer patients undergoing chemotherapy.

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A client with emphysema is reporting difficulty breathing and exhibiting 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

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