A nurse is reviewing medications for a client who has just been diagnosed with a small bowel obstruction. The nurse should withhold senna prescribed orally based on understanding of which of the following?

A. Repeating instructions: Repeating instructions can reinforce learning but does not guarantee that the patient has correctly understood or can apply the instructions. It does not provide an opportunity for the nurse to observe and correct errors.
B. Assessing lung sounds: Assessing lung sounds helps evaluate the effectiveness of the inhaled medication but does not verify whether the patient is using the inhaler correctly.
C. Return demonstration: A return demonstration involves the patient showing the nurse how they use the inhaler. This allows the nurse to observe the technique and provide immediate feedback and correction, ensuring proper use.
D. Answering questions: Answering questions can clarify doubts and enhance understanding, but it does not confirm that the patient is correctly using the inhaler.

A. Respiratory rate and pulse: Albuterol is a bronchodilator that works by relaxing the muscles in the airways, improving airflow and reducing wheezing and shortness of breath. After administration, it is important to monitor the respiratory rate to assess the patient’s breathing status and any changes in work of breathing. The pulse should also be monitored because albuterol can cause tachycardia as a side effect. An increase in heart rate is a common reaction to this medication and needs to be assessed to ensure it remains within safe limits.
B. Glucose: Monitoring glucose levels is not typically necessary after administering albuterol unless the patient has diabetes or there is a specific concern for hyperglycemia. Albuterol can cause an increase in blood glucose levels, but this is usually not a primary concern for an acute respiratory distress assessment unless the patient has an underlying condition that warrants it.
C. Pulse oximetry: Pulse oximetry measures the oxygen saturation in the blood, which is crucial for evaluating the effectiveness of albuterol in improving oxygenation. An increase in oxygen saturation levels after administration would indicate improved ventilation and gas exchange. Given that the patient initially has a pulse oximetry reading of 91%, it is important to reassess this to ensure that oxygen levels are improving with treatment.
D. Capillary refill: While capillary refill is an important general assessment for perfusion and circulatory status, it is not specifically required to evaluate the effectiveness of albuterol. It is more relevant in assessing overall circulation rather than the respiratory status directly impacted by albuterol.
E. Lung sounds: Reassessing lung sounds is critical after administering albuterol. The goal is to observe for changes such as reduced wheezing or improved airflow, which would indicate that the bronchodilator is effectively opening the airways. Listening for any changes in breath sounds helps to evaluate the patient’s response to the medication and detect any potential complications like paradoxical bronchospasm.