A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (Select all that apply)

Suctioning is the priority observation in the client's care, as it prevents airway obstruction and respiratory distress caused by blood, mucus, or secretions. The client has a permanent tracheostomy and cannot cough

or clear the airway effectively. The nurse should assess the need for suctioning frequently and perform it as needed, using sterile technique and maintaining oxygenation.

a) Patency of the intravenous line is important, but not the priority observation in the client's care. The intravenous line provides fluids, electrolytes, and medications to the client, but it does not affect the airway patency or oxygenation.
c) Integrity of the dressing is important, but not the priority observation in the client's care. The dressing protects the surgical site from infection and bleeding, but it does not affect the airway patency or oxygenation.
d) Level of pain is important, but not the priority observation in the client's care. The pain can be managed with analgesics and nonpharmacological measures, but it does not affect the airway patency or oxygenation.

Answer: A, B D

Rationale:

• Albuterol is a bronchodilator, and one of its key effects is to relax the muscles around the airways, which helps prevent wheezing. Wheezing is often caused by narrowed airways, and by opening them, albuterol helps to prevent this sound, which is associated with asthma or other respiratory conditions.

• B. The medication will decrease coughing episodes:
  Albuterol can help decrease coughing in individuals with conditions like asthma or chronic obstructive pulmonary disease (COPD) by relaxing the muscles in the airways, which reduces airway constriction. Since coughing often occurs due to airway obstruction, albuterol’s bronchodilator effect can help alleviate this symptom.

• C. The medication will reduce inflammation: Albuterol does not have anti-inflammatory properties. Its primary mechanism is bronchodilation, and anti-inflammatory treatment generally requires corticosteroids, not beta-agonists like albuterol.

• D. The medication will open the airways:
  This is correct. Albuterol works as a bronchodilator, meaning it opens up the airways by relaxing the smooth muscles surrounding them. This improves airflow and makes breathing easier, which is why it is often used in conditions like asthma or COPD.

• E. The medication will stimulate flow of mucus: Albuterol does not stimulate mucus production; it primarily works by relaxing the airways. However, by improving airflow, it can help clients more effectively expel mucus through coughing.