A nurse is assessing a client after receiving albuterol via nebulizer. The client reports feeling "nervous and shaky”. Which of the following responses by the nurse is correct?
"This is a common side effect with albuterol and will stop soon."
"You are having an allergic reaction, and I should notify the provider" -
"The albuterol is probably interacting with another medication.
"The albuterol is not working, and you will need another medication.
The Correct Answer is A
A. "This is a common side effect with albuterol and will stop soon." Nervousness and shakiness are common side effects of albuterol due to its action as a bronchodilator and stimulant.
B. "You are having an allergic reaction, and I should notify the provider." The symptoms described are not indicative of an allergic reaction but rather a common side effect of the medication.
C. "The albuterol is probably interacting with another medication." While drug interactions can occur, the reported symptoms are typical side effects of albuterol.
D. "The albuterol is not working, and you will need another medication." The symptoms do not indicate that the medication is ineffective; they are more indicative of its stimulant effects.
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Correct Answer is D
Explanation
A. Digoxin: Digoxin requires caution with elevated potassium levels, as hyperkalemia can increase the risk of digoxin toxicity. A potassium level of 5.3 mEq/L is borderline high, so it should be used cautiously.
B. Lisinopril: Lisinopril, an ACE inhibitor, can also increase potassium levels. It may not be the best choice for this client due to the elevated potassium.
C. Potassium iodide: Potassium iodide would further increase the client's potassium level and is contraindicated.
D. Furosemide: Furosemide is a loop diuretic that can help to lower serum potassium levels by promoting potassium excretion. Therefore, it is appropriate for this client with an elevated potassium level.
Correct Answer is ["A","C","D"]
Explanation
A. Perform passive range of motion exercises. Passive range of motion exercises help maintain circulation and reduce venous stasis, which is crucial for preventing pulmonary embolism in clients who are immobile.
B. Place pillows under the client's knees when in bed. Placing pillows under the knees can actually promote venous stasis and increase the risk of a pulmonary embolism. It is better to keep the legs flat to encourage circulation.
C. Assess legs for redness. Regular assessment of the legs for redness, swelling, or warmth helps in the early detection of deep vein thrombosis (DVT), which can lead to pulmonary embolism if not addressed.
D. Apply elastic compression stockings. Elastic compression stockings promote venous return from the legs to the heart and help prevent DVT, thereby reducing the risk of pulmonary embolism.
E. Massage the calves every shift. Massaging the calves can dislodge a thrombus and potentially lead to a pulmonary embolism. Instead, interventions should focus on preventing thrombus formation.