A nurse is caring for a client who received two doses of albuterol via nebulizer. Which of the following findings should the nurse expect during an assessment?
Bradycardia
Wheezing
Tremors
Sleepiness
The Correct Answer is C
Rationale:
A. Bradycardia: Albuterol can cause an increase in heart rate (tachycardia) as a common side effect, not a decrease in heart rate, so bradycardia would not be expected.
B. Wheezing: Albuterol is used to relieve wheezing by causing bronchodilation, so continued wheezing after administration would suggest ineffective treatment rather than being an expected finding.
C. Tremors: Tremors are a common side effect of albuterol due to its stimulation of beta-2 receptors in the muscles. This is often seen after nebulizer treatments.
D. Sleepiness: Albuterol generally causes stimulation of the central nervous system, leading to restlessness or nervousness, not sleepiness.
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Correct Answer is D
Explanation
Rationale:
A. Acetylcysteine is not indicated for gastrointestinal bleeding; other treatments are used for that condition.
B. Acute bronchospasm is treated with bronchodilators rather than acetylcysteine.
C. Morphine toxicity requires other interventions, such as opioid antagonists (e.g., naloxone), and acetylcysteine is not effective in this case.
D. Acetylcysteine is specifically indicated for acetaminophen toxicity as it acts as an antidote, replenishing glutathione stores and preventing liver damage from toxic metabolites.
Correct Answer is C
Explanation
Rationale:
A. Applying a warming blanket is not appropriate, as it may exacerbate the client's reaction to the infusion and is not a standard pre-medication strategy.
B. Infusing amphotericin B deoxycholate over 1 hour is too rapid; it is typically infused over 2-6 hours to minimize adverse effects.
C. Administering diphenhydramine prior to the administration of amphotericin B can help prevent or alleviate infusion-related reactions such as fever and chills, which the client experienced during previous infusions.
D. Monitoring vital signs once per hour following administration is insufficient; vital signs should be monitored more frequently during and immediately after the infusion to promptly detect and address any adverse reactions.