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.
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.
 
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Obtaining arterial blood gases is important for assessing respiratory status but is not the immediate priority. 
B. Administering an antipyretic can help reduce fever but does not address the immediate respiratory distress the client is experiencing. 
C. Offering an analgesic can improve comfort but is not the priority intervention in this scenario. 
D. Suctioning to clear secretions from the airway is the most critical intervention to improve the client’s respiratory status, especially given the weak cough effort and use of accessory muscles, indicating possible airway obstruction or ineffective clearance of secretions.
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