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: Notifying the healthcare provider of the carbamazepine level is not necessary, as 8.4 mg/L (35.6 mcmol/L) is within
the normal range of 4 to 12 mg/L (16.9 to 50.8 mcmol/L). The healthcare provider may adjust
the dose based on other factors such as clinical response, seizure frequency, or adverse effects,
but not based on this level alone.
Choice B reason: Administering the carbamazepine as prescribed is the appropriate action to take, as 8.4 mg/L (35.6 mcmol/L) is within
the normal range of 4 to 12 mg/L (16.9 to 50.8 mcmol/L). The nurse should follow the prescribed
dose and schedule of carbamazepine to maintain a therapeutic level and prevent seizures.
Choice C reason: Assessing the client for side effects of carbamazepine is important, as carbamazepine can cause adverse effects such as drowsiness, dizziness, nausea, rash, or blood dyscrasias. However, this action is not related to the carbamazepine level, as side effects can occur at any level and may not correlate with the serum concentration. The nurse should monitor the client for side effects regardless of the carbamazepine level.
Choice D reason: Withholding this dose of carbamazepine is not appropriate, as 8.4 mg/L (35.6 mcmol/L) is withinthe normal range of 4 to 12 mg/L (16.9 to 50.8 mcmol/L). Withholding the dose may cause a drop in the serum concentration and increase the risk of seizures. The nurse should administer the carbamazepine as prescribed unless instructed otherwise by the healthcare provider.
Correct Answer is C
Explanation
Choice B reason: Naloxone may be necessary, but first, the source of overdose (patches) must be removed to prevent further opioid absorption. After removal, the nurse should assess the severity and then administer naloxone if needed.
Choice A reason: Applying oxygen face mask is not the first action that the nurse should take in this situation, but rather a supportive measure that can be done after administering naloxone. Oxygen can help to improve the client's oxygenation and prevent hypoxia, but it will not reverse the opioid overdose.
Choice C reason: The client is exhibiting signs of opioid overdose, including respiratory depression (shortness of breath) and decreased level of consciousness (difficult to arouse). The first priority is to remove the excess morphine patches to stop further opioid absorption and prevent worsening of the overdose.
Choice D reason: Monitoring blood pressure is not the first action that the nurse should take in this situation, but rather an ongoing assessment that can be done after administering naloxone. Monitoring blood pressure can help to detect any changes in the client's hemodynamic status and guide further interventions, but it will not reverse the opioid overdose.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.