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 A
Explanation
A. Daily or weekly weight: Daily or weekly weight measurements are a reliable way to assess fluid retention. A sudden increase in weight can indicate fluid overload.
B. Sodium level: While sodium levels can provide some information about fluid balance, they are not as direct or reliable as weight measurements for assessing fluid retention.
C. Tissue turgor: Tissue turgor can give some insight into hydration status but is subjective and less reliable compared to weight measurements, especially in clients with chronic conditions.
D. Intake and output: While monitoring intake and output is important for assessing fluid balance, it may not accurately reflect fluid retention, as it doesn't account for fluid shifts or loss through other routes.
Correct Answer is D
Explanation
A. "This may mean that your liver is failing and you need immediate medical attention." This statement is misleading; orange-red urine is not typically a sign of liver failure, especially in the context of a urinary tract infection.
B. "This is an expected finding for someone with a diet high in red meat." While diet can affect urine color, red meat is not commonly associated with orange-red urine; this is not a relevant response given the client's context.
C. “This is a symptom that your urinary tract infection is worsening. I will notify the provider.” While it is important to monitor urinary tract infections, orange-red urine is more likely related to the use of phenazopyridine rather than a worsening infection.
D. “This is an expected finding if you are taking the over-the-counter medication, Phenazopyridine.” Phenazopyridine is known to cause orange-red discoloration of urine, and this statement provides reassurance to the client regarding their symptoms