An adult patient presents to the emergency department with complaints of shortness of breath and increased work of breathing.

Assessment

The patient is alert and oriented times 3, skin is pink, warm and dry. BP 148/88, T98, P92. R 24, pulse oximetry 91% on room air. Assessment of the lung reveals expiratory wheezing throughout the lung fields.

The physician orders an albuterol nebulizer. What assessments should the nurse plan to complete after administering the albuterol?

(Select All that Apply.)

A. This is normal.
Guaifenesin is an expectorant medication commonly used to help loosen and thin mucus in the airways, making it easier to cough up. Coughing up phlegm after taking guaifenesin is a typical and expected response to the medication. Therefore, reassuring the client that this is a normal effect of the medication is appropriate.

B. This requires further investigation: Coughing up phlegm after taking guaifenesin is a common and expected outcome, so further investigation is not necessary unless there are other concerning symptoms or indications.

C. This is indicative of an allergic reaction: Coughing up phlegm after taking guaifenesin is not indicative of an allergic reaction. Allergic reactions to guaifenesin are rare and typically present with more severe symptoms such as rash, itching, swelling, or difficulty breathing.

D. This means there is probably more pathology present: Coughing up phlegm after taking guaifenesin does not necessarily indicate the presence of additional pathology. Guaifenesin is intended to help clear mucus from the airways and is commonly used in the treatment of respiratory conditions associated with excess mucus production, such as cough due to cold or bronchitis.

A) Low-back pain:
Low-back pain is not typically associated with transfusion reactions. While certain complications of blood transfusions, such as transfusion-related acute lung injury (TRALI) or hemolytic reactions, can cause back pain, diphenhydramine is not specifically administered to prevent this manifestation.

B) Fever:
Fever can be a manifestation of various transfusion reactions, including febrile non-hemolytic reactions or bacterial contamination of blood products. However, diphenhydramine is not typically administered to prevent fever associated with transfusion reactions. Instead, measures such as leukoreduction of blood products or premedication with acetaminophen may be used to reduce the risk of febrile reactions.

C) Dyspnea:
Dyspnea, or difficulty breathing, can occur in severe transfusion reactions such as transfusion-related acute lung injury (TRALI) or anaphylaxis. While diphenhydramine may be part of the treatment for anaphylaxis, it is not specifically administered to prevent dyspnea associated with transfusion reactions.

D) Urticaria.
Urticaria, commonly known as hives, is a common manifestation of an allergic transfusion reaction. Diphenhydramine is an antihistamine medication that can help prevent or alleviate allergic reactions, including urticaria, by blocking the action of histamine, a substance released during allergic reactions. Administering diphenhydramine before a blood transfusion is a preventive measure to reduce the risk of allergic transfusion reactions, including urticaria.