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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Correct Answer is A
Explanation
Choice A rationale
Reviewing with the client the need to avoid foods rich in milk and cream is crucial. Dairy products can increase gastric acid secretion, which can exacerbate duodenal ulcers.
Choice B rationale
Suggesting frequent small meals can help reduce discomfort but does not address the issue of dairy products exacerbating the ulcer.
Choice C rationale
Switching to decaffeinated coffee and tea is beneficial but not as critical as avoiding dairy products.
Choice D rationale
Reinforcing teaching by asking the client to list dairy foods does not address the need to avoid these foods.
Correct Answer is D
Explanation
Choice A rationale
Observing pupil response of the right eye is not relevant to the care of the left eye post-cataract extraction.
Choice B rationale
Sleeping flat in a supine position is not recommended as it can increase intraocular pressure. Elevating the head is advised.
Choice C rationale
Turning, coughing, and deep breathing every 2 hours is not specific to cataract surgery and can increase intraocular pressure.
Choice D rationale
Administering a stool softener is important to prevent straining during bowel movements, which can increase intraocular pressure and affect healing.