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?
Irregular rapid heart rate.
Uncontrollable shaking.
Increased anxiety.
Throat irritation.
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
Restricting fluids is not a primary limitation for clients with Crohn’s disease. Adequate hydration is important for overall health and managing symptoms.
Choice B rationale
Limiting foods high in calcium and iron is not typically recommended for Crohn’s disease. These nutrients are important for maintaining bone health and preventing anemia, which can be concerns for individuals with Crohn’s disease.
Choice C rationale
An elimination diet can help identify trigger foods that may exacerbate symptoms of Crohn’s disease. This approach involves removing certain foods from the diet and gradually reintroducing them to determine which foods cause symptoms.
Choice D rationale
Avoiding gluten is not necessary for all individuals with Crohn’s disease. While some may benefit from a gluten-free diet, it is not a universal recommendation for managing the condition.
Correct Answer is A
Explanation
Choice A rationale
The severity of nausea and vomiting and serum amylase results are crucial in diagnosing and managing pancreatitis. Elevated serum amylase levels are a key indicator of pancreatitis, and the severity of nausea and vomiting can help assess the patient’s condition and response to treatment.
Choice B rationale
Reports of chronic constipation and serum gastrin levels are not directly related to the acute management of pancreatitis. Chronic constipation is more associated with gastrointestinal motility disorders, and serum gastrin levels are typically measured in conditions like Zollinger-Ellison syndrome.
Choice C rationale
Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts are not directly relevant to the acute management of pancreatitis. H. pylori is associated with peptic ulcer disease, and urine output is more relevant in assessing renal function.
Choice D rationale
The presence of bowel sounds and the degree of abdominal pain are important but not as specific as serum amylase levels in diagnosing pancreatitis. Bowel sounds can be affected by various conditions, and abdominal pain is a common symptom in many gastrointestinal disorders.