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 C

Explanation

Choice A reason: A cool, humidified air is not relevant for this client, as it does not affect the eyes or vision. A cool, humidified air may be beneficial for clients with respiratory conditions, such as asthma or bronchitis.

Choice B reason: A quiet, restful environment is not specific for this client, as it does not address the effects of mydriatic medication on the eyes or vision. A quiet, restful environment may be helpful for clients with stress, anxiety, or insomnia.

Choice C reason: A dimly lit room is the best environment for this client, as it reduces the glare and discomfort caused by mydriatic medication. Mydriatic medication is a type of eye drop that dilates the pupils and prevents them from constricting in response to light. This can improve the examination of the retina and optic nerve, but it also makes the eyes more sensitive to light and reduces the ability to focus on near objects.

Choice D reason: A warm room temperature is not necessary for this client, as it does not affect the eyes or vision. A warm room temperature may be comfortable for clients with cold intolerance, such as hypothyroidism or Raynaud's phenomenon.

A. Apply oxygen face mask. B. Administer a narcotic reversal drug. C. Remove the morphine patches. D. Monitor blood pressure.

Correct Answer is B

Explanation

Choice B reason: Administering a narcotic reversal drug, such as naloxone, is the first action that the nurse should take in this situation. The client is showing signs of opioid overdose, such as respiratory depression, sedation, and confusion. Naloxone can reverse these effects by blocking the opioid receptors in the brain and restoring normal breathing and consciousness.

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: Removing the morphine patches is not the first action that the nurse should take in this situation, but rather a preventive measure that can be done after administering naloxone. Removing the patches can help to stop the absorption of more morphine into the bloodstream and prevent further toxicity, but it will not reverse the opioid 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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A female client who is a vegetarian has a new prescription for warfarin. The client states she eats leafy green vegetables every day. How should the nurse respond?

A client with benign prostatic hyperplasia receives a new prescription of tamsulosin. Which intervention should the nurse perform to monitor for an adverse reaction?

The nurse is preparing a discharge teaching plan for a client who is taking ciprofloxacin hydrochloride tablets, which were prescribed because of a suspected anthrax exposure. Which instruction(s) should be included in the teaching plan? (Select all that apply.)

The healthcare provider prescribes the antibiotic tetracycline HCl for an adult client that arrived at an outpatient clinic. Which instruction should the nurse include in the teaching plan for this client?

A client taking atorvastatin develops an increased serum creatine phosphokinase (CK) level. The nurse should assess the client for the onset of which problem?

A client with Parkinson's disease who is taking carbidopa/levodopa reports that urine appears to be darker in color. Which action should the nurse take?

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?