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 ["10"]
Explanation
To administer the correct dose of valproic acid, which is 500 mg, when the available oral solution concentration is 250 mg per 5 mL, the nurse needs to calculate the volume of the solution required.
The calculation is as follows: (500 mg) / (250 mg/5 mL) = 2 x 5 mL = 10 mL.
Therefore, the nurse should administer 10 mL of the valproic acid oral solution to deliver a dose of 500 mg.
Correct Answer is A
Explanation
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.
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