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. It is accurate that vaccination is most effective before symptoms appear, but this statement does not address the client's immediate need for treatment.
B. Oseltamivir (Tamiflu) is an antiviral medication that can be prescribed for influenza symptoms if taken within the first 48 hours of symptom onset, making it appropriate to refer the client for a prescription.
C. While over-the-counter medications may help alleviate some symptoms, they do not treat the underlying viral infection, and antiviral medications can be more effective.
D. This statement is true but does not directly answer the client's question about the treatment of influenza with oseltamivir.
Correct Answer is C
Explanation
A. A hemoccult test on sputum is used to detect blood and is not specific to TB.
B. A positive PPD skin test indicates exposure to TB but does not confirm active disease; further testing is required.
C. A sputum culture positive for Mycobacterium tuberculosis is the definitive test for confirming active tuberculosis, as it isolates the organism.
D. A chest x-ray or CT can suggest the presence of TB but does not provide a definitive diagnosis; culture is necessary for confirmation.
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