Nokea
Before administering a prescribed bronchodilator to a client experiencing acute breathing distress, which of the following would be appropriate for the nurse to assess? Select all that apply.
- A. Blood pressure
- B. Blood glucose
- C. Pulse
- D. Lung sounds
- E. Respiratory rate
Correct Answer: A,C,D,E
Rationale: Prior to initiation of a bronchodilator during acute breathing distress, the nurse needs to assess vital signs, including blood pressure, pulse, and respiratory rate and lung sounds.
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A client is prescribed albuterol for bronchospasm in chronic bronchial asthma. Which of the following nursing diagnoses would the nurse expect to see on the care plan as a result of the adverse reaction of albuterol?
- A. Anxiety
- B. Risk of Impaired Oral Mucous Membranes
- C. Ineffective Tissue Perfusion
- D. Risk of Injury
Correct Answer: A
Rationale: The nurse would most likely identify a nursing diagnosis of Anxiety related to the adverse reaction of albuterol. A nursing diagnosis of Risk of Impaired Mucous Membranes may be seen with the use of corticosteroids, which increase the risk of oral candidiasis. There is no increased risk of injury or ineffective tissue perfusion with the use of albuterol therapy.
A client with asthma has been prescribed an antiasthmatic drug. Before administering the drug, the nurse assesses the respiratory rate of the client. The nurse notifies the primary health care provider based on which finding?
- A. 10 breaths/min
- B. 14 breaths/min
- C. 18 breaths/min
- D. 22 breaths/min
Correct Answer: A
Rationale: The nurse should consider 10 breaths/min an abnormal respiratory rate and notify the primary health care provider. Respiratory rates below 12 breaths/min or above 24 breaths/min are considered abnormal. A respiratory rate between 12 breaths/min and 24 breaths/min is considered normal.
A nurse is caring for a 30-year-old client who is receiving albuterol for asthma. The client complains of feeling dizzy, especially when he stands up after sitting. The nurse suspects that a possible interaction with another drug could be causing the client's problem. Which of the following drugs should the nurse consider as a possible cause?
- A. Warfarin
- B. Uterine stimulants
- C. Methylxanthines
- D. Methyldopa
Correct Answer: D
Rationale: The nurse should consider methyldopa as a cause for the client's complaint of dizziness on standing, suggesting hypotension. Methyldopa and albuterol interact, leading to hypotension. Albuterol does not interact with warfarin. Interaction between albuterol and uterine stimulants leads to severe hypotension, and not severe headache. There is an increased risk of cardiotoxicity when methylxanthines are given along with albuterol.
A pediatric client is prescribed cromolyn. The nurse understands that this drug can be administered in which manner? Select all that apply.
- A. Via a nebulizer
- B. Orally
- C. Nasal spray
- D. Metered-dose inhaler
- E. Subcutaneous injection
Correct Answer: A,B,C,D
Rationale: Cromolyn may be administered via a nebulizer, as an aerosol metered spray, as a nasal spray, or orally. It is not given subcutaneously.
The nurse instructs a client with asthma to always carry a rescue inhaler or quick-relief medication with him at all times. Which of the following would the client most likely carry? Select all that apply.
- A. Salmeterol (Serevent)
- B. Metaproterenol (Alupent)
- C. Tiotropium (Spiriva)
- D. Albuterol (Proventil)
- E. Formoterol (Foradil)
Correct Answer: B,D
Rationale: Short-acting beta agonists (SABAs) such as metaproterenol and albuterol are used as rescue treatment for asthma. Salmeterol and formoterol are long-acting beta agonists (LABAs). Tiotropium is a cholinergic blocking drug used to treat bronchospasm associated with COPD.