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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Neutropenic precautions are necessary when the WBC count is critically low, typically below the normal range. Since the client’s WBC count is now within the normal range, these precautions are no longer required.
Choice B reason: Filgrastim is designed to increase white blood cell (WBC) production in individuals with neutropenia. In this case, the client’s WBC count has increased from 2,500/mm³ (2.5 x 10⁹/L) to 5,000/mm³ (5 x 10⁹/L), reaching the lower limit of the normal reference range (5,000 to 10,000/mm³ or 5 to 10 x 10⁹/L). This indicates that the medication has achieved its desired effect, and it is appropriate to inform the client of this positive outcome.
Choice C reason:reason: Reviewing culture and sensitivity reports would be relevant if there was evidence of infection or a need to evaluate ongoing treatment for an infection. This is not indicated by the scenario provided.
Choice D reason: While assessing vital signs is generally important, there is no indication in this scenario that an acute issue requiring immediate vital sign monitoring is present.
Correct Answer is D
Explanation
Choice A reason: Telling the client to notify the nurse if the pain is not relieved is an important nursing action, but it is not the highest priority. The nurse should assess the client's pain level before and after administering the medication, and evaluate its effectiveness. If the pain is not relieved, the nurse should report it to the prescriber and consider other interventions.
Choice B reason: Advising the client that the medication should start to work in about 30 minutes is an informative nursing action, but it is not the highest priority. The nurse should educate the client about the expected onset, peak, and duration of action of the medication, and how to take it safely and effectively. However, this does not address any immediate risks or needs of the client.
Choice C reason: Administering a stool softener/laxative at the same time as the analgesic is a preventive nursing action, but it is not the highest priority. The nurse should anticipate and prevent potential side effects of the medication, such as constipation, which can be caused by codeine. However, this does not address any urgent or emergent issues of the client.
Choice D reason: Instructing the client to request assistance when ambulating to the bathroom is the highest priority nursing action, as it addresses a serious safety concern of the client. The nurse should protect the client from falls and injuries, which can be caused by codeine's sedative and drowsy effects. The nurse should also monitor the client's respiratory rate and level of consciousness, as codeine can cause respiratory depression and altered mental status.
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