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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

Trouble sleeping is not directly relevant to the administration of pyridostigmine, which is used to improve muscle strength in myasthenia gravis.

Choice B rationale

Unexplained weight loss is not a primary concern when administering pyridostigmine. The focus should be on the patient’s ability to swallow and recent oral intake.

Choice C rationale

Difficulty with urination is not a primary concern for pyridostigmine administration. The medication’s effects on muscle strength and swallowing are more critical.

Choice D rationale

Recent oral intake is crucial to assess because pyridostigmine can cause gastrointestinal side effects, and food intake can affect its absorption and effectiveness.

Correct Answer is C

Explanation

Choice A rationale

Topical antifungals are used to treat fungal infections and are not effective for psoriasis, which is an autoimmune condition.

Choice B rationale

Colloidal oatmeal-based lotion can help soothe the skin but does not address the underlying inflammation and scaling associated with psoriasis.

Choice C rationale

Topical corticosteroids are the mainstay of treatment for psoriasis. They help reduce inflammation, itching, and redness associated with psoriatic plaques.

Choice D rationale

Topical analgesics can help relieve pain but do not address the underlying inflammation and scaling associated with psoriasis.

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