Nokea
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.
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The ABG analysis results reveal that the client's partial pressure of arterial carbon dioxide (PaCO2) is 65 mm Hg. The nurse recognizes that this is abnormal because normal PaCO2 levels fall between which values?
- A. 7.35 and 7.45
- B. 80 and 100 mm Hg
- C. 35 and 45 mm Hg
- D. 22 and 26 mm Hg
Correct Answer: C
Rationale: Normal PaCO2 levels are 35 to 45 mm Hg; a value of 65 mm Hg indicates hypercapnia, common in COPD.
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.
If the client complains of GI side effects associated with rifampin (Rifadin), which nursing action is best?
- A. Administering the drug at night
- B. Giving the drug with food or at mealtimes
- C. Encouraging the client to drink plenty of water
- D. Providing the client with an antacid
Correct Answer: B
Rationale: Giving rifampin with food can reduce gastrointestinal side effects, such as nausea, without compromising its efficacy.
An adult has a chest drainage system. Several hours after the chest tube was inserted, the nurse observes that there is no bubbling in the water seal chamber. What is the most likely reason for the absence of bubbling?
- A. The client's lungs have reexpanded.
- B. There is an obstruction in the tubing coming from the client.
- C. There is a mechanical problem in the pump.
- D. Air is leaking into the drainage apparatus.
Correct Answer: A
Rationale: No bubbling in the water seal chamber typically indicates lung reexpansion, as air is no longer leaking from the lung into the pleural space.
While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
- A. Suction deeper to pick up secretions
- B. Gently withdraw suction tubing to allow suction or coughing out of mucus
- C. Remove the suction as quickly as possible
- D. Put the suction tube in and out several times to pick up secretions
Correct Answer: C
Rationale: Removing the suction quickly allows the client to cough out mucus naturally, preventing irritation or trauma.