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
Monitoring daily urine output volume is important for assessing fluid balance, but it does not directly address the issue of hypernatremia. Hypernatremia is characterized by high sodium levels in the blood, and monitoring urine output alone will not help in managing sodium intake or identifying sources of excess sodium.
Choice B rationale
Using salt tablets after strenuous exercise is not recommended for clients with hypernatremia. Salt tablets can increase sodium levels further, exacerbating the condition. Hypernatremia requires careful management of sodium intake, and salt tablets would be counterproductive.
Choice C rationale
Reviewing food labels for sodium content is crucial for clients with hypernatremia. This helps them identify and avoid foods high in sodium, which can contribute to elevated sodium levels in the blood. Educating clients on reading food labels empowers them to make informed dietary choices and manage their condition effectively.
Choice D rationale
Drinking plenty of water whenever thirsty is a general recommendation for maintaining hydration, but it does not specifically address hypernatremia. Clients with hypernatremia need to focus on managing their sodium intake and ensuring they do not consume excessive amounts of sodium.
Correct Answer is A
Explanation
Choice A rationale
Lactulose is a synthetic sugar used to treat hepatic encephalopathy by reducing the absorption of ammonia in the intestines. Ammonia is a neurotoxin that can impair mental status in patients with liver dysfunction. By decreasing ammonia levels, lactulose helps improve cognitive function and mental status in patients with hepatic encephalopathy.
Choice B rationale
While lactulose can cause diarrhea as a side effect, the therapeutic goal in hepatic encephalopathy is not to reduce the number of liquid stools but to lower ammonia levels in the blood. The reduction in ammonia levels leads to improved mental status, not necessarily a reduction in liquid stools.
Choice C rationale
The ability to ambulate independently is not a direct therapeutic response to lactulose. The primary goal of lactulose therapy in hepatic encephalopathy is to improve mental status by reducing ammonia levels, not to enhance physical mobility.
Choice D rationale
Lactulose does not have a direct effect on urine output. Its primary mechanism of action is to reduce ammonia absorption in the intestines, thereby improving mental status in patients with hepatic encephalopathy.