Nokea
A patient with asthma is receiving a nebulizer of Cromolyn. The patient reports a burning sensation in the nose along with a horrible taste in their mouth. As the nurse you will?
- A. Immediately stop the nebulizer
- B. Re-adjust the nebulizer
- C. Call a rapid response because the patient is having a potential anaphylactic reaction to the medication.
- D. Reassure the patient this is a temporary side effect of this medication.
Correct Answer: D
Rationale: Burning sensation and bad taste are common temporary side effects of Cromolyn nebulizer treatment and do not indicate a severe reaction.
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After levalbuterol hydrochloride (Xopenex) administration, which client symptom does the nurse evaluate as a side effect of the medication?
- A. Respiratory rate of 28 breaths/minute
- B. Heart rate of 96 beats/minute
- C. Blood pressure of 100/60 mm Hg
- D. Drowsiness
Correct Answer: B
Rationale: Levalbuterol, a beta-agonist, commonly causes an increased heart rate as a side effect due to its stimulatory effects.
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication?
- A. The client's partial thromboplastin time (PTT) is 38.
- B. The client's international normalized ratio (INR) is 5.
- C. The client's prothrombin time (PT) is 22.
- D. The client's erythrocyte sedimentation rate (ESR) is 10.
Correct Answer: B
Rationale: An INR of 5 (B) is above the therapeutic range (2–3 for pulmonary embolus), indicating excessive anticoagulation and bleeding risk, so warfarin should be questioned. PTT (A) is for heparin, not warfarin. PT (C) alone is not standardized. ESR (D) is irrelevant to anticoagulation.
Which datum requires immediate intervention by the nurse for the client diagnosed with asbestosis?
- A. The client develops an S3 heart sound.
- B. The client has clubbing of the fingers.
- C. The client is fatigued in the afternoon.
- D. The client has basilar crackles in all lobes.
Correct Answer: A
Rationale: An S3 heart sound (A) indicates heart failure, a serious complication in asbestosis due to pulmonary hypertension, requiring immediate intervention. Clubbing (B) is a chronic finding, not acute. Fatigue (C) is common but not urgent. Basilar crackles (D) are expected in asbestosis and less critical than cardiac issues.
Because of this client's impaired speech, which nursing action facilitates communication?
- A. Discourage the client's attempts at communication.
- B. Inform the client to speak slowly when talking.
- C. Listen attentively to the client's vocalizations.
- D. Provide the client with paper and pencil.
Correct Answer: D
Rationale: Providing paper and pencil allows the client with impaired speech post-laryngectomy to communicate effectively through writing.
An adult is admitted with chronic obstructive pulmonary disease [COPD]. The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset of which of the following?
- A. Pneumothorax
- B. Cor pulmonale
- C. Cardiogenic shock
- D. Left-sided heart failure
Correct Answer: B
Rationale: Neck vein distention and peripheral edema indicate right-sided heart failure, or cor pulmonale, caused by pulmonary hypertension in COPD.