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
Isoniazid is an antitubercular drug used to treat active tuberculosis. The effectiveness of this medication is evaluated by observing a decrease in symptoms such as cough and sputum production. This indicates that the infection is being controlled and the bacteria are being eradicated.
Choice B rationale
A positive sputum smear and culture would indicate the presence of active tuberculosis bacteria, suggesting that the treatment is not effective. Therefore, this is not an expected outcome of effective treatment.
Choice C rationale
Decreased appetite and weight loss are not indicators of the effectiveness of tuberculosis treatment. In fact, these symptoms could indicate a worsening of the condition or side effects of the medication.
Choice D rationale
Vertigo and tinnitus are not related to the effectiveness of tuberculosis treatment. These symptoms could be side effects of the medication but do not indicate the success of the treatment.