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.)
Respiratory rate and pulse
Pulse oximetry
Capillary refill
Glucose
Lung sounds
Correct Answer : A,B,E
A. Respiratory rate and pulse: Albuterol is a bronchodilator medication commonly used to relieve bronchospasm in conditions like asthma and chronic obstructive pulmonary disease (COPD). Monitoring the patient's respiratory rate and pulse is essential to assess the response to the medication and any potential adverse effects.
B. Pulse oximetry: Albuterol helps to open the airways and improve oxygenation in patients with bronchospasm. Monitoring oxygen saturation using pulse oximetry provides valuable information about the patient's respiratory status and response to treatment.
C. Capillary refill: Capillary refill is typically assessed to evaluate peripheral perfusion and circulation. While it is an important assessment in certain clinical situations, it is not directly related to monitoring the response to albuterol administration.
D. Glucose: Glucose monitoring is not typically indicated after administering albuterol nebulizer unless the patient has a history of diabetes or there are specific concerns regarding glucose levels.
E. Lung sounds: Assessing lung sounds before and after administering albuterol helps to evaluate the effectiveness of the medication in relieving bronchospasm. Improvement in lung sounds, such as decreased wheezing or clearer breath sounds, indicates a positive response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) H2-receptor blockers:
H2-receptor blockers, such as ranitidine and famotidine, are commonly used to reduce stomach acid production and treat peptic ulcer disease. They help promote ulcer healing and alleviate symptoms. These medications are generally safe and appropriate for use in clients with peptic ulcer disease.
B) Antacids:
Antacids are medications that neutralize stomach acid and provide symptomatic relief from peptic ulcer disease. While they do not directly treat the underlying cause of the ulcer, they can help alleviate symptoms such as pain and discomfort. Antacids are generally safe for use in clients with peptic ulcer disease.
C) PPIs (Proton Pump Inhibitors):
PPIs, such as omeprazole and pantoprazole, are potent acid-suppressing medications commonly used to treat peptic ulcer disease and gastroesophageal reflux disease (GERD). They are effective at reducing stomach acid production and promoting ulcer healing. PPIs are generally safe and appropriate for use in clients with peptic ulcer disease.
D) NSAIDs (Nonsteroidal Anti-Inflammatory Drugs).
NSAIDs, such as ibuprofen, aspirin, and naproxen, can exacerbate peptic ulcer disease by increasing the risk of gastric irritation, erosion, and ulceration. These medications inhibit the production of prostaglandins, which help protect the stomach lining. Chronic or excessive use of NSAIDs can lead to the development of new ulcers or worsening of existing ulcers. Therefore, clients with peptic ulcer disease are typically advised to avoid NSAIDs or to use them with caution under the guidance of a healthcare provider.
Correct Answer is C
Explanation
A) Treatment with PPIs to decrease stomach acid:
Proton-pump inhibitors (PPIs) are used to decrease stomach acid production and are commonly prescribed for conditions such as gastroesophageal reflux disease (GERD) and peptic ulcers. However, they do not address the underlying cause of pancreatic insufficiency, which is the deficiency of pancreatic enzymes.
B) Treatment with stimulant laxatives:
Stimulant laxatives are used to stimulate bowel movements and are not indicated for the treatment of pancreatic insufficiency. Pancreatic insufficiency primarily affects the digestion of nutrients rather than bowel motility.
C) Replacement therapy with pancreatic enzymes.
Pancreatic insufficiency occurs when the pancreas does not produce enough digestive enzymes to properly digest food, leading to malabsorption of nutrients. Replacement therapy with pancreatic enzymes is the mainstay of treatment for pancreatic insufficiency. These enzymes, often prescribed in the form of pancreatic enzyme replacement therapy (PERT), help to supplement the deficient enzymes and aid in the digestion of fats, proteins, and carbohydrates.
D) Decrease food intake:
Decreasing food intake is not an appropriate treatment for pancreatic insufficiency. In fact, individuals with pancreatic insufficiency may need to increase their food intake to compensate for malabsorption and ensure adequate nutrition. Restricting food intake would worsen nutritional deficiencies and symptoms associated with malabsorption.
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