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 B
Explanation
Choice A rationale
Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice B rationale
Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.
Choice C rationale
Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice D rationale
Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.
Correct Answer is A
Explanation
Choice A rationale
pH 7.49, PCO₂ 45 mm Hg, HCO₃ 32 mEq/L (32 mmol/L), PO₂ 90 mm Hg indicates metabolic alkalosis. The elevated pH and HCO₃ levels are consistent with this condition.
Choice B rationale
pH 7.30, PCO₂ 20 mm Hg, HCO₃ 22 mEq/L (22 mmol/L), PO₂ 85 mm Hg indicates metabolic acidosis with respiratory compensation, not metabolic alkalosis.
Choice C rationale
pH 7.46, PCO₂ 55 mm Hg, HCO₃ 36 mEq/L (36 mmol/L), PO₂ 95 mm Hg indicates metabolic alkalosis with respiratory compensation. However, the pH is slightly lower than in Choice A, making Choice A more indicative of metabolic alkalosis.
Choice D rationale
pH 7.29, PCO₂ 35 mm Hg, HCO₃ 25 mEq/L (25 mmol/L), PO₂ 99 mm Hg indicates metabolic acidosis, not metabolic alkalosis.