After administering the prescribed albuterol nebulizer treatment, what should the nurse assess?
Heart rate
Breath sounds
Serum sodium levels
Complete blood count
Oxygen saturation
Peak inspiratory flow
Temperature
Peak expiratory flow
Correct Answer : B,E,H
H.
Choice A rationale
While albuterol can cause an increase in heart rate due to its beta-agonist effects, it is not the primary assessment following administration. The main goal of albuterol treatment is to improve respiratory function.
Choice B rationale
Breath sounds are a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve breath sounds by reducing bronchospasm and increasing airflow.
Choice C rationale
Serum sodium levels are not directly affected by albuterol and therefore are not a primary assessment following its administration.
Choice D rationale
A complete blood count is not directly affected by albuterol and therefore is not a primary assessment following its administration.
Choice E rationale
Oxygen saturation is a primary assessment following albuterol administration. Albuterol should improve oxygen saturation by increasing airflow and oxygen delivery.
Choice F rationale
Peak inspiratory flow is not typically assessed after albuterol administration. Albuterol primarily affects expiratory flow by reducing bronchospasm.
Choice G rationale
Temperature is not directly affected by albuterol and therefore is not a primary assessment following its administration.
Choice H rationale
Peak expiratory flow is a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve peak expiratory flow by reducing bronchospasm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The patient vomiting at home for 3 days prior to surgery is crucial information that the PACU nurse should report. This could indicate a pre-existing condition or complication that needs to be addressed in the patient’s post-operative care plan.
Choice B rationale
While the patient refusing to take ice chips despite complaining of dry mouth is an important observation, it is not as critical as the patient’s pre-operative condition (vomiting for 3 days). The refusal of ice chips could be addressed through patient education and encouragement.
Choice C rationale
The presence of peripheral pulses and full range of motion in both legs is expected and normal in a post-operative patient, unless there were complications during surgery that could affect these observations. Therefore, this information, while important, is not as critical as the patient’s pre-operative condition.
Choice D rationale
The condition of the patient’s abdomen (soft, bowel sounds absent) and the absence of bleeding on the dressing are expected observations in a patient who has undergone an exploratory laparotomy. These observations, while important, do not provide additional critical information that the PACU nurse should report.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
A rotator cuff injury could be a possibility given the patient’s age and the nature of the fall. The rotator cuff is a group of muscles and tendons that surround the shoulder joint, and injuries to this area are common in falls where the shoulder takes the impact.
Choice B rationale
A humeral fracture could also be a possibility. The humerus is the bone in the upper arm, and it can be fractured in falls, especially in older adults who may have weaker bones.
Choice C rationale
A concussion could be a possibility given that the patient hit his head on the wall. Symptoms of a concussion can include nausea and fatigue, which the patient is experiencing.
Choice D rationale
A knee sprain could be a possibility given that the patient is experiencing pain in his right knee. Sprains occur when the ligaments, which are the bands of tissue that hold bones together, are stretched or torn.
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