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 B
Explanation
A. While attaching humidification can be beneficial for patients with respiratory issues, the immediate priority is to assess the client's oxygenation status.
B. Obtaining a pulse oximetry reading is crucial to determine the client's oxygen saturation level and guide further interventions.
C. Coaching through huff coughing is helpful, but it is more important to first assess oxygenation to understand the severity of the dyspnea.
D. Providing a nebulizer treatment can be an important intervention, but it should follow the assessment of the client's oxygen levels to determine if immediate treatment is necessary.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
- Hypoxia is a condition in which there is a deficiency of oxygen in the tissues, which is consistent with the client’s low oxygen saturation of 89% on room air and 97% on supplemental oxygen.
- The diminished concentration of inhaled oxygen refers to the inadequate oxygen availability, which is a significant concern in pneumonia as it affects gas exchange in the lungs, leading to hypoxia.
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