After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields.

Which action should the nurse take next based on the assessment?

Use a peak flow meter to assess the respiratory status.

Administer a stat dose of corticosteroids.

Document the normal finding in the client's health record.

Repeat a dose of the client's rescue drug.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Use a peak flow meter to assess the respiratory status. Assessing the client's respiratory status using a peak flow meter is the most appropriate next action after administering albuterol, a bronchodilator. It helps determine the client's lung function and response to the medication. This information guides further interventions and treatment decisions.

Choice B rationale:

Administer a stat dose of corticosteroids. Administering corticosteroids may be indicated in some cases of respiratory distress or exacerbation of asthma. However, it should not be the immediate next step after albuterol administration. Assessing the client's response to albuterol through lung function testing (peak flow) is essential before deciding on additional medications.

Choice C rationale:

Document the normal finding in the client's health record. Documenting normal findings is important for maintaining accurate medical records, but in this case, it is premature. The nurse should first assess the client's response to albuterol and ensure that the respiratory status is indeed normal before documenting the findings.

Choice D rationale:

Repeat a dose of the client's rescue drug. Administering another dose of the rescue drug (albuterol) without assessing the client's response and lung function would not be the most appropriate action. It is essential to determine whether the initial dose was effective before considering additional doses or alternative treatments.

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Correct Answer is B

Explanation

Choice A rationale:

Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.

Choice B rationale:

Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.

Choice C rationale:

Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.

Choice D rationale:

Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.

A. “You can continue to take calcium supplements as long as you take them with food.”. B. “You should avoid taking calcium supplements while you are on tetracycline therapy.”. C. “You can take calcium supplements with tetracycline as long as you drink plenty of water.”. D. “You should take calcium supplements at least 2 hours before or after tetracycline.”.

Correct Answer is D

Explanation

Choice A rationale:

Tetracycline antibiotics can form insoluble complexes with calcium, reducing their absorption when taken together. Therefore, advising the client to continue taking calcium supplements with food while on tetracycline therapy is not recommended as it may decrease the effectiveness of the antibiotic.

Choice B rationale:

The nurse should advise the client to avoid taking calcium supplements while on tetracycline therapy. Calcium-containing products (such as supplements, dairy products, and antacids) should be taken at least 2 hours before or after tetracycline administration to minimize the interference with drug absorption.

Choice C rationale:

Taking calcium supplements with tetracycline, even with plenty of water, can still lead to reduced drug absorption due to the formation of insoluble complexes. Therefore, this advice is not appropriate.

Choice D rationale:

The nurse should recommend that the client take calcium supplements at least 2 hours before or after tetracycline. This approach ensures that the client receives the full therapeutic benefit of the antibiotic while still meeting their calcium needs separately.

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After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse notes that the client’s oxygen saturation is 88% on room air. What is the priority action by the nurse?

Correct Answer is B

Explanation

A nurse is administering tetracycline to a client who has acne vulgaris. The client tells the nurse that he usually takes calcium supplements with his meals. How should the nurse respond?

Correct Answer is D

Explanation

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After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields.

Which action should the nurse take next based on the assessment?