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A client with emphysema is reporting difficulty in breathing and exhibiting audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

A.

Irregular rapid heart rate.

B.

Uncontrollable shaking.

C.

Increased anxiety.

D.

Throat irritation.

Answer and Explanation

The Correct Answer is A

Choice A rationale

 

Irregular rapid heart rate (tachycardia) is a serious side effect of albuterol and warrants immediate intervention. Albuterol is a beta-2 agonist that can cause stimulation of beta-1 receptors in the heart, leading to tachycardia and potential arrhythmias.

 

Choice B rationale

 

Uncontrollable shaking (tremors) is a common side effect of albuterol due to its stimulation of beta-2 receptors in skeletal muscles. While uncomfortable, it is not typically life-threatening.

 

Choice C rationale

 

Increased anxiety can occur with albuterol use due to its stimulant effects on the central nervous system. However, it is not as immediately dangerous as tachycardia.

 

Choice D rationale

 

Throat irritation is a minor side effect of albuterol and does not require immediate intervention.


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Securing tracheostomy ties by making knots close to the tube can cause irritation and pressure on the skin.

Choice B rationale

Removing ties to secure a disposable, soft foam collar with hook and loop fastener is not the most important action when changing the ties of the tracheostomy tube.

Choice C rationale

Leaving the old ties in place until the new ones are secure is the most important action to prevent accidental dislodgement of the tracheostomy tube.

Choice D rationale

Placing knots of the ties laterally to prevent irritation and pressure is important but not the most critical action when changing the ties of the tracheostomy tube.

Correct Answer is A

Explanation

Choice A rationale

Hematemesis, or vomiting blood, is a critical sign of bleeding esophageal varices, which can be life-threatening. Clients with chronic cirrhosis and esophageal varices are at high risk for variceal bleeding due to increased portal hypertension. Monitoring for hematemesis is essential to provide timely intervention and prevent complications.

Choice B rationale

Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.

Choice C rationale

Clay-colored stool indicates a lack of bile in the stool, which can occur in liver disease. However, it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.

Choice D rationale

Brown, foamy urine can be a sign of liver dysfunction, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.

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