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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 D

Explanation

Choice A rationale

Determining the neurological baseline prior to the fall is important but not the immediate priority. The client’s current confusion and projectile vomiting suggest a potential acute condition that needs immediate assessment.

Choice B rationale

Determining the client’s last dose of corticosteroids is relevant for managing multiple sclerosis but does not address the immediate concern of confusion and vomiting.

Choice C rationale

Administering a PRN IV antiemetic as prescribed can help manage vomiting but does not address the underlying cause of the symptoms.

Choice D rationale

Completing a head-to-toe neurological assessment is the priority intervention. The client’s confusion and projectile vomiting could indicate increased intracranial pressure or another acute neurological condition that requires immediate attention.

Correct Answer is C

Explanation

Choice A rationale

Potatoes are naturally gluten-free and safe for individuals with celiac disease.

Choice B rationale

Corn chips are also naturally gluten-free and safe for individuals with celiac disease.

Choice C rationale

Oatmeal can be contaminated with gluten during processing, making it unsafe for individuals with celiac disease unless it is certified gluten-free.

Choice D rationale

Fried rice is typically gluten-free, but it is essential to ensure that no gluten-containing ingredients or cross-contamination occurs during preparation.

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