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Difficulty: HardPharmacological Therapies

A practical nurse is caring for a client admitted with an acute asthma exacerbation. The client is receiving continuous oxygen therapy and is scheduled for a nebulized albuterol treatment. Upon assessment, the client's vital signs are: blood pressure 142/88 mmHg142/88\text{ mmHg}, heart rate 116 beats/min116\text{ beats/min}, respiratory rate 26 breaths/min26\text{ breaths/min}, and oxygen saturation 90%90\% on 2 L/min2\text{ L/min} via nasal cannula. The client reports feeling anxious with a "racing heart," and the nurse observes fine bilateral hand tremors. Which action should the practical nurse take?

  1. Administer the nebulized albuterol as prescribed and evaluate the client's respiratory response.Answer
  2. B
    Withhold the albuterol treatment due to the tachycardia and immediately notify the registered nurse (RN).
  3. C
    Instruct the unlicensed assistive personnel (UAP) to continuously monitor the client's pulse oximetry during the treatment.
  4. D
    Reassure the client by stating, "Do not worry, this medication will stop your heart from racing very soon."

Answer

The practical nurse should administer the nebulized albuterol as prescribed and evaluate the client's respiratory response.
Albuterol is a short-acting beta-2 adrenergic agonist used to cause bronchodilation. Expected side effects include tachycardia, palpitations, anxiety, and tremors. Because the client is experiencing an acute asthma exacerbation with hypoxia (SpO2 90%90\%) and tachypnea, administering the bronchodilator is the highest priority to maintain the airway and improve breathing. The nurse should administer the medication and continue to monitor the client's response.

Step-by-Step Solution

1
Analyze the client's vital signs and physical assessment findings.
The client has tachypnea (respiratory rate 26), hypoxia (SpO2 90%), tachycardia (heart rate 116), anxiety, and fine hand tremors.
To determine the client's current physiological status and identify emergent needs.
2
Evaluate the clinical findings in relation to the prescribed pharmacological therapy (albuterol).
Albuterol is a bronchodilator critically needed for the asthma exacerbation. Tachycardia, anxiety, and tremors are known, expected side effects of beta-2 agonists.
To differentiate between expected medication side effects and contraindications for administration.
3
Prioritize nursing actions based on the ABCs (Airway, Breathing, Circulation).
Airway and breathing (treating the bronchospasm and hypoxia) take precedence over the expected cardiovascular side effects.
In emergent situations, life-threatening airway issues must be addressed first.
4
Determine the appropriate intervention within the practical nurse's scope of practice.
The nurse should administer the scheduled medication to relieve the bronchospasm and closely monitor the client's response.
Ensuring the client receives timely, life-saving pharmacological therapy for an acute exacerbation is a primary nursing responsibility.

Key Concept

Albuterol Administration and ABC Prioritization
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Topics

Pharmacological Therapies

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