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 ["B","D"]
Explanation
A. Diabetes: Diabetes is not typically a contraindication for decongestant use. However, patients with diabetes should be cautious with decongestants that contain sugar or other ingredients that may affect blood glucose levels.
B. Hypertension: Decongestants can cause vasoconstriction, which may lead to an increase in blood pressure. Patients with hypertension should use decongestants cautiously and under the guidance of a healthcare provider to avoid exacerbating their condition.
C. Hyperthyroidism: While decongestants can stimulate the sympathetic nervous system and may exacerbate symptoms of hyperthyroidism such as tachycardia and palpitations, hyperthyroidism is not typically considered a contraindication for decongestant use. However, patients with hyperthyroidism should use decongestants cautiously and consult with their healthcare provider.
D. Heart disease: Decongestants can increase heart rate and blood pressure, potentially exacerbating symptoms in patients with underlying heart conditions such as coronary artery disease, heart failure, or arrhythmias. Patients with heart disease should use decongestants cautiously and consult with their healthcare provider before use.
E. Allergic rhinitis: Allergic rhinitis is not typically a contraindication for decongestant use. In fact, decongestants are often used to relieve nasal congestion associated with allergic rhinitis. However, patients with allergic rhinitis should use decongestants cautiously and follow the recommended dosage instructions.
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