A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis?

A. Acute bronchospasm:

Albuterol (Proventil) is commonly used to treat acute bronchospasm, which is characterized by sudden constriction of the muscles surrounding the airways. This constriction leads to narrowing of the air passages, making it difficult to breathe. Albuterol works as a bronchodilator by relaxing these muscles, thereby opening up the airways and relieving symptoms such as wheezing, shortness of breath, and chest tightness. It is commonly used to manage conditions such as asthma, chronic obstructive pulmonary disease (COPD), and bronchitis, where bronchospasm is a prominent feature.

B. Acute allergies:

Albuterol (Proventil) is not typically used to treat acute allergies. While it can help alleviate symptoms such as wheezing and shortness of breath that may occur as a result of allergic reactions affecting the airways, its primary indication is for bronchospasm associated with respiratory conditions like asthma and COPD. Antihistamines and corticosteroids are more commonly used to manage allergic reactions and their associated symptoms.

C. Nasal congestion:

Albuterol (Proventil) is not indicated for the treatment of nasal congestion. Nasal congestion primarily involves swelling and inflammation of the nasal passages, which are not directly affected by albuterol. Decongestants such as pseudoephedrine or nasal corticosteroids are typically used to relieve nasal congestion by reducing inflammation and swelling in the nasal passages.

D. Dyspnea on exertion:

Albuterol (Proventil) may help alleviate dyspnea (shortness of breath) on exertion, particularly if it is caused by bronchospasm or exercise-induced bronchoconstriction. By relaxing the muscles around the airways, albuterol can improve airflow and ease breathing difficulties associated with exertion. However, it is important to note that albuterol is primarily indicated for the treatment of acute bronchospasm rather than dyspnea on exertion unrelated to bronchospasm. Other interventions, such as oxygen therapy or addressing underlying cardiovascular conditions, may be necessary to manage dyspnea on exertion in those cases.

A. Turn off the ventilator alarms before suctioning the client's airway.

This choice is incorrect because it goes against standard practice. Ventilator alarms are critical for monitoring the patient's respiratory status and detecting any issues with the ventilator or the patient's airway. Turning off alarms before suctioning can lead to missed alarms and potentially dangerous situations for the patient.

B. Provide mouth care every 10 to 12 hr with hydrogen peroxide.

This choice is incorrect because using hydrogen peroxide for mouth care is not recommended. Hydrogen peroxide can be irritating to the mucosa and may cause harm to the patient's oral tissues. Instead, gentle oral care with an appropriate solution, such as a mouthwash specifically designed for oral hygiene in ventilated patients, is preferred. Mouth care should also be provided more frequently than every 10 to 12 hours to maintain oral hygiene and prevent complications such as ventilator-associated pneumonia.

C. Place the head of the client's bed at 40° when supine.

This choice is correct. Proper positioning of the patient is crucial for optimizing ventilation and preventing complications such as aspiration and ventilator-associated pneumonia. Elevating the head of the bed to 40 degrees when the patient is in a supine position helps to minimize the risk of aspiration by promoting drainage of secretions away from the airway and improving lung expansion.

D. Reposition the client every 4 hr.

This choice is not directly related to care for clients receiving mechanical ventilation. While repositioning the patient every 4 hours is important for preventing pressure ulcers and maintaining skin integrity, it is not specific to mechanical ventilation care. However, it is still an important aspect of overall patient care, particularly for patients who are immobile or confined to bed for extended periods.