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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.

Respiratory rate and pulse

B.

Pulse oximetry

C.

Capillary refill

D.

Glucose

E.

Lung sounds

Answer and Explanation

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.
 


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Related Questions

Correct Answer is C

Explanation

To calculate the rate of administration in milliliters per hour (mL/hr):

First, find the total volume to be infused: 1000 mL

Next, divide the total volume by the total time in hours: 1000 mL ÷ 5 hours = 200 mL/hr

Therefore, you will administer the solution at a rate of 200 mL/hr.

To calculate the rate of administration in drops per minute (drops/min):

First, find the total drops: 1000 mL × 15 drops/mL = 15,000 drops

Next, divide the total drops by the total time in minutes: 15,000 drops ÷ (5 hours × 60 minutes/hour) = 50 drops/min

Therefore, you will administer the solution at a rate of 200 mL/hr and 50 drops/min.

Correct Answer is D

Explanation

A) Inspiration:
Inspiration refers to the process of inhaling or breathing in air into the lungs. It involves the contraction of the diaphragm and expansion of the chest cavity, leading to the intake of air into the lungs.

B) Expiration:
Expiration, also known as exhalation, refers to the process of exhaling or breathing out air from the lungs. It involves the relaxation of the diaphragm and chest muscles, leading to the expulsion of air from the lungs.

C) Respiration:
Respiration is a broader term that encompasses both ventilation (the mechanical process of breathing) and gas exchange (the exchange of oxygen and carbon dioxide between the lungs and blood). While respiration involves both air movement and gas exchange, it does not specifically refer to blood flow through the lung, which is described by the term perfusion.

D) Perfusion.
Perfusion refers to the circulation of blood through the lung's blood vessels, including the pulmonary arteries and pulmonary capillaries. This process allows for the exchange of gases (oxygen and carbon dioxide) between the blood and the air in the lungs during respiration. Perfusion is essential for oxygenating blood and removing carbon dioxide, which is crucial for maintaining normal cellular function throughout the body.

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