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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Administering an antacid relieves epigastric pain but is premature without assessing pain characteristics. Pain in peptic ulcer disease may indicate complications like perforation, requiring urgent evaluation. Assessment guides whether antacids or other interventions are appropriate, prioritizing patient safety.
Choice B reason: Assessing pain characteristics (e.g., location, intensity, radiation) is the first step, as epigastric pain in peptic ulcer disease may signal complications like bleeding or perforation. This data guides interventions, ensuring timely management of potentially life-threatening conditions, making it the priority action.
Choice C reason: Checking NSAID use identifies ulcer triggers but is secondary to pain assessment. Pain characteristics determine urgency, as severe or radiating pain may indicate perforation, requiring immediate action. Assessment provides critical data before investigating contributing factors like medication history.
Choice D reason: Obtaining a stool sample for occult blood detects gastrointestinal bleeding but is not the first step. Assessing pain characteristics identifies urgent complications like perforation, guiding whether diagnostic tests or interventions are needed, making pain assessment the initial priority.
Correct Answer is A
Explanation
Choice A reason: Assisting with mobility and fall prevention is critical in Parkinson’s disease, as bradykinesia and rigidity increase fall risk. Physical therapy and assistive devices enhance safety, reducing injury risk, making this the priority intervention to maintain functional independence and prevent fractures.
Choice B reason: High-protein meals may interfere with levodopa absorption in Parkinson’s, worsening symptoms. Mobility assistance is the priority, as falls are a leading cause of injury, requiring immediate intervention to ensure safety, making dietary protein secondary to physical support.
Choice C reason: Restricting fluid intake is inappropriate, as hydration prevents constipation in Parkinson’s. Mobility and fall prevention are critical, as motor symptoms increase injury risk. Assisting with mobility addresses the primary functional challenge, making fluid restriction irrelevant to priority care.
Choice D reason: Promoting social isolation worsens depression in Parkinson’s, a common comorbidity. Mobility assistance is the priority, as falls due to motor impairment are a significant risk, requiring immediate intervention to ensure safety, making social isolation counterproductive to care.
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