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 an expected response and indicates that the medication is working as intended. Guaifenesin helps to clear the airways of excess mucus, which can be particularly beneficial for individuals with respiratory conditions such as bronchitis or chest congestion.

B) This requires further investigation.
Coughing up phlegm after taking guaifenesin is a common and expected response and does not typically indicate a need for further investigation unless there are other concerning symptoms present. It is important for the nurse to provide reassurance and education about the expected effects of the medication.

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 but may include symptoms such as rash, itching, swelling, dizziness, or difficulty breathing. If the client were experiencing these symptoms, it would be important to assess further for a possible allergic reaction and intervene accordingly.

D) This means there is probably more pathology present.
Coughing up phlegm after taking guaifenesin does not necessarily indicate the presence of more pathology. It simply indicates that the medication is helping to loosen and mobilize mucus in the airways, which is a normal response to expectorant therapy. If the client has concerns about their symptoms, further assessment by a healthcare provider may be warranted, but coughing up phlegm alone is not necessarily indicative of worsening pathology.

A) A client who has a kidney stone:
Misoprostol is not contraindicated in clients who have kidney stones. Kidney stones are not a known contraindication for the use of misoprostol.

B) A client who is pregnant.
Misoprostol is a medication commonly used to prevent gastric ulcers in individuals who are taking nonsteroidal anti-inflammatory drugs (NSAIDs) for conditions such as osteoarthritis. However, it is contraindicated in pregnant women due to its potential to cause uterine contractions, leading to miscarriage or preterm labor. Misoprostol is classified as a pregnancy category X medication, meaning that there is clear evidence of fetal risk based on human or animal studies, and its use is contraindicated during pregnancy.

C) A client who has a urinary tract infection:
Misoprostol is not contraindicated in clients who have urinary tract infections. Urinary tract infections are not a known contraindication for the use of misoprostol.

D) A client who has osteoarthritis:
Misoprostol is commonly used in clients with conditions such as osteoarthritis to prevent NSAID-induced gastric ulcers. Osteoarthritis is not a contraindication for the use of misoprostol when indicated for gastric ulcer prevention in individuals taking NSAIDs.