A client with pneumonia who has an emergent episode of respiratory distress is intubated and transferred to the intensive care unit. The client's chest x-ray shows consolidation in the left lobe, and physical assessment reveals diminished lung sounds. The nurse administers acetylcysteine as prescribed per nebulization via endotracheal tube. Which therapeutic response of this medication should the nurse expect?

Bronchodilation and wheezing.

Unpleasant smell when using the medication.

Increased sputum, requiring suctioning.

Hypotension.

Answer and Explanation

The Correct Answer is C

Choice C reason: Acetylcysteine is a mucolytic agent that breaks down mucus and makes it easier to cough up or suction out. This helps to clear the airways and improve oxygenation. The nurse should expect to see increased sputum production after administering acetylcysteine and provide frequent suctioning as needed.

Choice A reason: Bronchodilation and wheezing are not therapeutic responses of acetylcysteine, but rather possible adverse effects. Acetylcysteine can cause bronchospasm or bronchoconstriction in some clients, especially those with asthma or chronic obstructive pulmonary disease (COPD). The nurse should monitor the client's breath sounds and oxygen saturation and report any signs of respiratory distress.

Choice B reason: Unpleasant smell when using the medication is not a therapeutic response of acetylcysteine, but rather a common side effect. Acetylcysteine has a rotten egg odor that can be unpleasant for both the client and the nurse. The nurse can minimize this by using a mouthwash or a flavored lozenge before and after administering acetylcysteine.

Choice D reason: Hypotension is not a therapeutic response of acetylcysteine, but rather a rare but serious adverse effect. Acetylcysteine can cause vasodilation or hypovolemia in some clients, leading to low blood pressure and shock. The nurse should monitor the client's vital signs and report any signs of hypotension.

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Correct Answer is A

Explanation

Choice A reason: This is the correct action to include in the client's plan of care, as sucralfate should be given on an empty stomach, at least one hour before meals and at bedtime. Sucralfate is a mucosal protectant that forms a protective barrier over the ulcer and prevents further damage from acid and pepsin. It requires an acidic environment to work, so it should not be taken with food or antacids.

Choice B reason: This is not a relevant action to include in the client's plan of care, as sucralfate does not cause or increase the risk of secondary Candida infection. Candida infection is a fungal infection that can affect the mouth, throat, esophagus, or vagina. It is more common in clients who use antibiotics, corticosteroids, or immunosuppressants, but not sucralfate.

Choice C reason: This is not an accurate action to include in the client's plan of care, as sucralfate should be administered four times a day, not once a day. Sucralfate has a short duration of action, so it needs to be taken frequently to maintain its protective effect on the ulcer.

Choice D reason: This is not a necessary action to include in the client's plan of care, as sucralfate does not cause or affect electrolyte imbalance. Electrolyte imbalance is an abnormality in the levels of sodium, potassium, calcium, magnesium, or other minerals in the blood. It can be caused by dehydration, vomiting, diarrhea, kidney disease, or other conditions, but not sucralfate.

A. Hemoglobin level of 13.5 g/dL (135 g/L). B. Serum glucose level of 120 mg/dL (6.7 mmol/L). C. Serum potassium level of 3.8 mEq/L (3.8 mmol/L). D. Serum ammonia level of 30 mg/dL (17.62 µmol/L).

Correct Answer is C

Explanation

Choice C reason: Sodium polystyrene sulfonate is a cation-exchange resin that binds to potassium in the intestine and removes it from the body through the stool. Sodium polystyrene sulfonate is used to treat hyperkalemia, or high potassium level, which can be caused by AKI, certain medications, or other conditions. Hyperkalemia can cause cardiac arrhythmias, muscle weakness, paralysis, or death. The normal range of potassium for adults is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore, a decrease in potassium from above normal to within normal indicates that sodium polystyrene sulfonate has been effective in lowering potassium level and preventing complications. The nurse should monitor the client's serum potassium level regularly and adjust the dose of sodium polystyrene sulfonate as needed.

Choice A reason: Hemoglobin level of 13.5 g/dL (135 g/L) is not a laboratory finding that indicates that the medication has been effective, but rather a normal value that reflects the amount of oxygen-carrying protein in the blood. Hemoglobin is not affected by sodium polystyrene sulfonate or potassium level. The normal range of hemoglobin for adults is 12 to 16 g/dL (120 to 160 g/L). Therefore, a hemoglobin level of 13.5 g/dL does not indicate any change or improvement in the client's condition.

Choice B reason: Serum glucose level of 120 mg/dL (6.7 mmol/L) is not a laboratory finding that indicates that the medication has been effective, but rather a slightly elevated value that reflects the amount of sugar in the blood. Glucose is not affected by sodium polystyrene sulfonate or potassium level. The normal range of glucose for adults is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Therefore, a serum glucose level of 120 mg/dL may indicate impaired glucose metabolism or diabetes mellitus, but not the effectiveness of sodium polystyrene sulfonate.

Choice D reason: Serum ammonia level of 30 mg/dL (17.62 µmol/L) is not a laboratory finding that indicates that the medication has been effective, but rather a normal value that reflects the amount of nitrogen waste in the blood. Ammonia is not affected by sodium polystyrene sulfonate or potassium level. The normal range of ammonia for adults is 10 to 80 mg/dL (6 to 47 µmol/L). Therefore, a serum ammonia level of 30 mg/dL does not indicate any change or improvement in the client's condition.

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Naxlex Comprehensive Predictor Exams

The nurse is planning to administer the antiulcer gastrointestinal (GI) agent sucralfate to a client with peptic ulcer disease. Which action should the nurse include in this client's plan of care?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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The nurse is planning the home care of a client who is receiving a mydriatic medication. Which environment is best for this client?

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