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. Increase fluids to 1L/per day. Clients with emphysema are often encouraged to increase fluid intake beyond 1 liter to help thin secretions, but 1 liter per day is generally insufficient.
B. Administer the medication with food. Theophylline should not necessarily be taken with food; it is generally taken on an empty stomach, but it can be taken with food if gastrointestinal upset occurs.
C. Consume a high-protein diet. High-protein diets may increase the metabolism of theophylline, potentially decreasing its therapeutic effect. Dietary considerations for theophylline involve avoiding caffeine.
D. Avoid caffeine while taking this medication. Theophylline is a methylxanthine, similar to caffeine, and consuming caffeine can increase the risk of side effects like tachycardia, nervousness, and insomnia.
Correct Answer is C
Explanation
A. Vitamin K: Vitamin K is used for anticoagulant reversal, not for acetaminophen toxicity.
B. Flumazenil: Flumazenil is a benzodiazepine antagonist and is not indicated for acetaminophen overdose.
C. Acetylcysteine: Acetylcysteine is the antidote for acetaminophen toxicity, helping to replenish glutathione stores and prevent liver damage.
D. Atropine: Atropine is used for bradycardia or certain poisoning but is not relevant for acetaminophen toxicity.