A client with emphysema is reporting difficulty in 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?

Uncontrollable shaking.

Increased anxiety.

Throat irritation.

Irregular rapid heart rate.

Answer and Explanation

The Correct Answer is D

A. Uncontrollable shaking can be a side effect of albuterol, but it is not as critical as other potential cardiovascular concerns.
B. Increased anxiety is common with respiratory distress but is not immediately life-threatening.
C. Throat irritation may occur but is generally not a severe concern compared to cardiovascular effects.
D. An irregular rapid heart rate is a significant sign of potential adverse effects from albuterol, indicating possible toxicity or worsening of the client’s condition, which requires immediate intervention.

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Correct Answer is B

Explanation

A. Increasing the frequency of dressing changes is not necessary unless there is excessive drainage or signs of infection; it may disrupt the healing process.
B. Applying a hydrocolloidal gel dressing is appropriate for a stage 3 pressure injury with granulation tissue as it promotes a moist healing environment and helps facilitate healing.
C. A transparent dressing may not provide adequate moisture retention or protection for a stage 3 pressure injury compared to a hydrocolloidal dressing.
D. Leaving the dressing off could expose the wound to infection and is not advisable without further assessment and consultation.

A. Aspirin. B. Loperamide. C. Ipratropium. D. Fargtidine.

Correct Answer is A

Explanation

A. Bismuth subsalicylate contains salicylate, which is related to aspirin; thus, reviewing the medication history for aspirin is essential to avoid potential toxicity or adverse effects, especially since both medications can increase the risk of bleeding.
B. Loperamide is an antidiarrheal medication and is not directly relevant to the treatment of H. pylori or contraindicated with the prescribed medications.
C. Ipratropium is a bronchodilator used for respiratory issues and is unrelated to H. pylori treatment.
D. Fargtidine, if intended to refer to a medication for gastrointestinal conditions, does not have direct relevance to the specific interactions that may arise with the prescribed regimen.

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A client with emphysema is reporting difficulty in 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

Naxlex Comprehensive Predictor Exams

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is B

Explanation

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection. Prior to administering the H. pylori treatment regimen, the nurse should review the electronic medical record for which medication?

Correct Answer is A

Explanation

A client with emphysema is reporting difficulty in 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?

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