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 A
Explanation
Rationale:
A. Requesting a serum trough level blood draw for 60 minutes after the completion of the infusion is appropriate for monitoring the therapeutic levels of vancomycin and ensuring it is within the desired range to prevent toxicity.
B. Changing the infusion site after each dose administration is not necessary unless there is an issue such as infiltration or phlebitis; typically, the site can be used for multiple doses if it remains patent and functional.
C. Contacting the provider for prescription clarification is not needed unless there are specific concerns about the medication or the administration protocol; in this case, the order is clear and standard.
D. Requesting a serum peak level to be drawn 30 minutes prior to infusion is incorrect, as the peak level should be drawn 30 minutes after the completion of the infusion, not before the next dose.
Correct Answer is C
Explanation
Rationale:
A. Sargramostim is a granulocyte-macrophage colony-stimulating factor (GM-CSF) used to stimulate the production of white blood cells but is not specifically indicated for anemia.
B. Filgrastim is a granulocyte colony-stimulating factor (G-CSF) that increases white blood cell counts and is not used for treating anemia.
C. Epoetin is an erythropoiesis-stimulating agent that stimulates red blood cell production, making it the appropriate choice for treating chemotherapy-induced anemia.
D. Romiplostim is a thrombopoietin receptor agonist used to treat thrombocytopenia (low platelet count) and is not indicated for anemia.