Nokea
A nurse is caring for an adult client who is receiving albuterol inhalation treatments. For which of the following adverse effects should the nurse monitor the client? (Select all that apply.)
- A. Shakiness
- B. Fatigue
- C. Tinnitus
- D. Tachycardia
- E. Palpitations
Correct Answer: A, D, E
Rationale: The correct adverse effects to monitor for with albuterol inhalation treatments are shakiness, tachycardia, and palpitations. Albuterol is a beta-2 adrenergic agonist that can cause sympathetic stimulation, leading to these specific side effects. Shakiness is due to the stimulation of beta-2 receptors in muscles, tachycardia results from the activation of beta-1 receptors in the heart, and palpitations can occur due to increased heart rate. Fatigue and tinnitus are not commonly associated with albuterol use, making choices B and C incorrect. In summary, the correct answers are related to the sympathetic effects of albuterol, while the incorrect choices are not typically seen with this medication.
You may also like to solve these questions
A nurse is reinforcing teaching with a client who has diabetes mellitus and takes insulin glargine and insulin aspart. Which of the following actions indicates that the client understands the instructions?
- A. The client administers insulin glargine at the same time every day.
- B. The client mixes insulin aspart and insulin glargine in the same syringe.
- C. The client administers insulin aspart 30 min before breakfast.
- D. The client stores open vials of insulin glargine at room temperature for 60 days.
Correct Answer: A
Rationale: The correct answer is A. Administering insulin glargine at the same time every day helps maintain consistent blood sugar levels due to its long-acting nature. Mixing insulin aspart and glargine is incorrect as they have different onset and duration of action. Administering insulin aspart 30 min before breakfast may not align with the client's meal timing. Storing open vials of insulin glargine at room temperature for 60 days exceeds the recommended storage duration, risking potency and efficacy.
Vital Signs Day 1: Temperature 37.2° C (99° F), Blood pressure 124/56 mm Hg, Heart rate 66/min, Respiratory rate 16/min, Oxygen saturation 95% on room air; Day 2: Temperature 37.2° C (99° F), Heart rate 112/min, Respiratory rate 28/min, Blood pressure 148/86 mm Hg, Oxygen saturation 90% on room air; Medication Administration Record: Albuterol 2 inhalations every 4 to 6 hr PRN wheezing, Bisacodyl 10 mg suppository daily PRN constipation, Prochlorperazine 10 mg PO 3 to 4 times per day PRN nausea, Morphine 4 mg IV bolus every 4 hr PRN severe pain, Acetaminophen 325 to 650 mg every 4 to 6 hr PRN pain or temperature greater than 38.4° C (101.1° F); Nurses' Notes Day 1: Bilateral breath sounds are clear and present throughout. Client reports pain as 2 on a scale of 0 to 10. Abdomen soft, nondistended, bowel sounds hypoactive. Client has a history of asthma. Day 2: Respirations rapid and shallow. Bilateral breath sounds with scattered wheezing. Client reports pain as 8 on a scale of 0 to 10. Client reports no nausea or constipation. Abdomen soft, nondistended, bowel sounds audible.
The nurse should contribute to the plan of care by administering _______ and ______ to the client.
- A. Prochlorperazine
- B. Albuterol
- C. Morphine
- D. Bisacodyl
- E. Acetaminophen
Correct Answer: B, C
Rationale: The correct answer is B and C. Albuterol is a bronchodilator used to treat respiratory conditions like asthma, while morphine is an opioid analgesic for pain management. The nurse should administer these medications as part of the client's plan of care to address their specific health needs. Prochlorperazine (A) is an antiemetic for nausea and vomiting, not typically within a nurse's scope. Bisacodyl (D) is a laxative, Acetaminophen (E) is a pain reliever, and the remaining choices are not provided.
A nurse is reinforcing teaching with the parents of a 1-year-old client following the administration of the measles, mumps, and rubella virus vaccine (MMR). Which of the following adverse effects should the nurse instruct the parents to report to the provider?
- A. Glandular swelling around the jaw
- B. Redness around the injection site
- C. Temperature 37.3° C (99.2° F)
- D. Shortness of breath
Correct Answer: D
Rationale: The correct answer is D: Shortness of breath. Shortness of breath can indicate a severe allergic reaction or anaphylaxis, which is a rare but serious adverse effect of the MMR vaccine. It is crucial to report this immediately to the healthcare provider for prompt evaluation and management to prevent any complications.
A: Glandular swelling around the jaw is a common and mild side effect of the MMR vaccine, typically resolving on its own and not requiring immediate medical attention.
B: Redness around the injection site is a common and expected reaction to the vaccine, usually resolving without intervention.
C: A temperature of 37.3° C (99.2° F) is a low-grade fever, which can be a normal response to vaccination and typically does not require urgent medical attention.
A nurse is reinforcing discharge teaching with a client who has a new diagnosis of type 2 diabetes mellitus and a prescription for exenatide. Which of the following instructions should the nurse include in the teaching?
- A. Contact the provider if you experience unexplained muscle pain.
- B. Inject the medication into the subcutaneous tissue of your abdomen.
- C. Take the medication at bedtime.
- D. Discard excess medication after 60 days.
Correct Answer: B
Rationale: The correct answer is B: Inject the medication into the subcutaneous tissue of your abdomen. Exenatide is a medication used to treat type 2 diabetes and is administered by subcutaneous injection. Injecting it into the abdomen allows for better absorption. It is important for the nurse to instruct the client on the correct administration technique to ensure the medication is effective.
Incorrect choices:
A: Contact the provider if you experience unexplained muscle pain - Although monitoring for side effects is important, muscle pain is not a common side effect of exenatide.
C: Take the medication at bedtime - Exenatide is typically taken before meals, not at bedtime.
D: Discard excess medication after 60 days - Exenatide must be refrigerated and has a shorter shelf life once opened, typically 30 days, not 60.
A nurse is reinforcing teaching with a client who has pancreatitis and a new prescription for pancrelipase. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take this medication whole.
- B. I can expect this medication to cure the pancreatitis.
- C. I should discontinue the medication if I develop fatty stools.
- D. I will take this medication at bedtime.
Correct Answer: A
Rationale: The correct answer is A: "I will take this medication whole." This is correct because pancrelipase should be taken whole to ensure the proper release of enzymes in the small intestine for digestion. Option B is incorrect because pancrelipase does not cure pancreatitis but helps with digestion. Option C is incorrect because fatty stools are expected side effects of pancrelipase and not a reason to discontinue the medication. Option D is incorrect because pancrelipase should be taken with meals or snacks, not specifically at bedtime.