A client with emphysema reports difficulty breathing and exhibits 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?

Regular rapid heartbeat.

Increased anxiety.

Uncontrollable shaking.

Throat irritation.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A regular rapid heartbeat (tachycardia) is a common side effect of albuterol, a bronchodilator that relaxes the muscles in the airways to improve breathing. It's often expected after repeated doses. While it warrants monitoring, it doesn't necessarily require immediate intervention unless it becomes significantly elevated or causes other symptoms.

Choice B rationale:

Increased anxiety can also accompany breathing difficulties and albuterol administration. It's crucial to address anxiety, but it's not the most urgent finding in this scenario. Calming techniques and reassurance can often help manage anxiety, while more severe cases might require additional interventions.

Choice C rationale:

Uncontrollable shaking (tremors) is a more serious side effect of albuterol, indicating excessive stimulation of the sympathetic nervous system. It can progress to serious complications like seizures or cardiac events. Immediate intervention is crucial to prevent these risks. Actions might include:

Holding the next albuterol dose Notifying the healthcare provider Monitoring vital signs closely

Administering medications to counteract the tremors, such as beta-blockers, if ordered

Choice D rationale:

Throat irritation is a possible side effect of albuterol, but it's generally mild and self-limiting. It doesn't typically warrant immediate intervention in the absence of other concerning symptoms.

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Correct Answer is A

Explanation

Choice A rationale:

Direct identification of the causative organism: A culture for sensitive organisms is the most direct and definitive way to identify the specific bacteria or other microorganisms that are causing the infection in the wound. This information is crucial for guiding the selection of the most appropriate antibiotic therapy.

Tailored antibiotic therapy: By knowing the exact organism responsible, healthcare providers can prescribe antibiotics that are specifically effective against that organism, ensuring optimal treatment and reducing the risk of antibiotic resistance.

Informed infection control measures: The results of the culture can also inform appropriate infection control measures to prevent the spread of the infection to other patients or healthcare workers.

Monitoring treatment effectiveness: Cultures can also be used to monitor the effectiveness of antibiotic therapy. If the culture results show that the bacteria are no longer present after a course of antibiotics, this indicates that the treatment has been successful.

Choice B rationale:

Non-specific marker of inflammation: C-reactive protein (CRP) is a non-specific marker of inflammation that can be elevated in various conditions, including infections, but also in non-infectious conditions such as autoimmune diseases and trauma.

Limited diagnostic value for wound infections: While an elevated CRP level may suggest the presence of an infection, it does not provide information about the specific causative organism, which is essential for guiding antibiotic therapy.

Supplementary role: CRP levels can be used in conjunction with other clinical findings and laboratory tests to assess the severity of an infection and monitor the response to treatment, but it should not be relied upon as a sole diagnostic tool for wound infections.

Choice C rationale:

Not directly indicative of wound infection: Blood pH level primarily reflects the acid-base balance of the body and is not directly indicative of a wound infection.

Alterations in other conditions: Blood pH can be altered in various conditions, including respiratory and metabolic disorders, and is not specific to wound infections.

Limited role in diagnosis: While significant alterations in blood pH may suggest a serious systemic infection, it does not provide information about the location or causative organism of the infection.

Choice D rationale:

Not directly related to wound infection: Serum blood glucose level is primarily used to monitor diabetes and is not directly related to wound infections.

Impaired wound healing in diabetes: While elevated blood glucose levels can impair wound healing and increase the risk of infections in diabetic patients, it is not a diagnostic test for wound infections in general.

Secondary consideration: Blood glucose levels may be considered as part of the overall assessment of a patient with a wound infection, particularly in those with diabetes, but it is not a primary diagnostic tool.

A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. B. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE). C. Report the COVID-19 result to the local health department according to Center for Disease Control (CDC) guidelines. D. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient.

Correct Answer is B

Explanation

Choice A rationale:

While teaching the client about infection prevention measures is important, it is not the most immediate priority in this situation. The client is already potentially contagious, and these measures may not be sufficient to prevent transmission if the client is not properly isolated.

It's crucial to remember that the client may be experiencing cognitive impairment due to illness, making it harder to fully comprehend and adhere to instructions.

Additionally, some clients may not have access to or be able to afford masks and hand sanitizer, potentially hindering compliance with these measures.

Choice B rationale:

Isolating the client is the most critical action to prevent the spread of COVID-19 to others. This includes separating the client from other patients, family members, and healthcare workers who are not wearing proper PPE.

PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the client, minimizing the risk of transmission via direct contact or droplets.

Proper isolation techniques include placing the client in a designated negative-pressure isolation room, if available, or designating a separate area within a multi-bed room.

It's essential to restrict the client's movement within the healthcare facility and limit visitors to essential personnel only.

Choice C rationale:

Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus; however, it is not the most immediate priority in this situation.

The priority is to prevent further transmission by isolating the client.

Choice D rationale:

Counseling family members to monitor for symptoms is important, but it is not the most immediate priority in this situation. The priority is to prevent transmission by isolating the client.

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A client with emphysema reports difficulty breathing and exhibits 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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A client with emphysema reports difficulty breathing and exhibits 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?