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

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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Correct Answer is ["5"]

Explanation

To determine how many hours it will take for the IV pump to infuse the 1000 mL bag of 0.9% sodium chloride at a rate of 200 mL/hr, we can use the following formula:

Time (hr) = Volume (mL)/Rate (mL/hr)

Given:

Volume = 1000 mL

Rate = 200 mL/hr

Substitute the given values into the formula:

Time (hr)=1000 mL/200 mL/hr

Time (hr)=5hours

Rounding to the nearest whole number, the IV pump will infuse over 5 hours.

Therefore, the nurse should expect the IV pump to infuse over 5 hours.

A. Hypotension. B. Liver failure C. Bradycardia. D. Hypertension

Correct Answer is D

Explanation

A. Hypotension: Norepinephrine is administered to treat hypotension, so monitoring for hypotension is not typically a concern while the patient is receiving this medication. In fact, hypotension is often the reason for administering norepinephrine in the first place.

B. Liver failure: Monitoring for signs of liver failure may be important in patients receiving certain medications, but it is not a specific consideration when administering norepinephrine. Norepinephrine primarily affects blood pressure regulation and does not typically have direct effects on liver function.

C. Bradycardia: While norepinephrine can increase blood pressure by constricting blood vessels, it may also cause reflex bradycardia (a decrease in heart rate) as a compensatory response. However, the primary concern with norepinephrine administration is hypertension, not bradycardia.

D. Hypertension
Norepinephrine (Levophed) is a vasopressor medication commonly used to treat hypotension and shock. It works by constricting blood vessels, which increases blood pressure. Therefore, when administering norepinephrine, the nurse should monitor the patient for hypertension, as the medication's intended effect is to raise blood pressure.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["5"]

Explanation

When administering norepinephrine (Levophed), the nurse monitors the patient for:

Correct Answer is D

Explanation

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