An adult patient is admitted for an asthma attack. Which assessment obtained by the nurse would support that beta2 adrenergic agonist albuterol was effective?
Decrease in wheezing present on auscultation
Respiratory rate increased to 38 breaths/min
Sputum production is clear and watery
Use of neck muscles
The Correct Answer is A
Choice A reason: Decrease in wheezing present on auscultation indicates that albuterol was effective. Albuterol is a bronchodilator that relaxes the smooth muscles of the airways and reduces the airway resistance. This improves the airflow and reduces the wheezing sound that is caused by the turbulent flow of air through the narrowed airways.
Choice B reason: Respiratory rate increased to 38 breaths/min does not indicate that albuterol was effective. It indicates that the patient is still experiencing respiratory distress and hypoxia. The normal respiratory rate for adults is 12 to 20 breaths/min. A high respiratory rate can also be a side effect of albuterol, as it can stimulate the sympathetic nervous system and increase the heart rate and blood pressure.
Choice C reason: Sputum production is clear and watery does not indicate that albuterol was effective. It indicates that the patient has a productive cough and is expelling mucus from the lungs. Sputum production is not directly affected by albuterol, as it does not have anti-inflammatory or mucolytic properties.
Choice D reason: Use of neck muscles does not indicate that albuterol was effective. It indicates that the patient is using accessory muscles to breathe and is exerting more effort to inhale. This is a sign of severe respiratory distress and airway obstruction. Albuterol should relieve the bronchospasm and reduce the need for accessory muscle use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the best response by the nurse. Stopping the medication abruptly can cause rebound hypertension and other complications. The patient should not stop taking the medication without consulting their health care provider.
Choice B reason: This is not the best response by the nurse. Cutting the pill in half and taking a reduced dosage can affect the efficacy and safety of the medication. The patient should not change the dosage of the medication without consulting their health care provider.
Choice C reason: This is the best response by the nurse. Dizziness is a common side effect of ACE inhibitors, especially when the patient changes position or stands up quickly. This is due to the orthostatic hypotension (a drop in blood pressure when standing up) caused by the vasodilation effect of the medication. However, this side effect is usually mild and transient, and can be prevented by rising slowly from a sitting or lying position, drinking plenty of fluids, and avoiding alcohol.
Choice D reason: This is not the best response by the nurse. Scheduling the patient to visit the health care provider today is not necessary, unless the dizziness is severe, persistent, or accompanied by other symptoms, such as chest pain, fainting, or palpitations. The patient should be advised to monitor their blood pressure and report any significant changes or concerns to their health care provider.
Correct Answer is C
Explanation
Choice A reason: An increase in antithrombotic substances is not a cause of atherosclerosis. Antithrombotic substances are agents that prevent or reduce the formation of blood clots. They can be used to treat or prevent atherosclerosis, not cause it.
Choice B reason: Congenital heart disease is not a cause of atherosclerosis. Congenital heart disease is a condition that is present at birth and affects the structure or function of the heart. It can be caused by genetic or environmental factors, not by atherosclerosis.
Choice C reason: Endothelial injury and inflammation are causes of atherosclerosis. Endothelial injury is the damage to the inner lining of the blood vessels, which can be caused by various factors such as high blood pressure, high cholesterol, smoking, or diabetes. Inflammation is the body's response to the injury, which involves the activation of immune cells and the release of cytokines and growth factors. These processes lead to the formation of plaque, which is composed of cholesterol, fatty substances, calcium, and other materials.
Choice D reason: High serum potassium levels are not a cause of atherosclerosis. High serum potassium levels are a condition that affects the balance of electrolytes in the blood. It can be caused by kidney disease, medication side effects, or excessive intake of potassium-rich foods. It can affect the heart rhythm and function, but it does not cause atherosclerosis.
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