Pharmacology Reproductive & Maternity Meds #1

Question

The nurse is caring for a client on a ventilator following acute respiratory distress syndrome and is about to administer respiratory treatment of acetylcysteine. Which priority action will the nurse prepare to perform after administration of acetylcysteine?

Answers

  1. Suctioning excess secretions.
    • Rationale:

      This answer is correct because acetylcysteine is a mucolytic when used by mouth, it helps thin and loosen mucus in the client’s airway. As the mucus is loosened, it needs to be suctioned so to not go back into the airway and cause a decrease in oxygen exchange.

  2. Turn, cough, and deep breathe the client.
    • Rationale:

      This answer is not correct because turn, cough, deep breath is not the best action following administration of acetylcysteine. Acetylcysteine is a mucolytic when used by mouth, it helps thin and loosen mucus in the client’s airway. As the mucus is loosened, it needs to be suctioned so as to not go back into the airway and cause decrease in oxygen exchange.

  3. Instruct the client that the medication may cause bradycardia.
    • Rationale:

      This answer is not correct because acetylcysteine does not cause bradycardia. The mucolytic has no significant effect on heart rate.

  4. Remove any acetaminophen from the medication administration record.
    • Rationale:

      This answer is not correct because this medication is being administered to treat respiratory distress syndrome to loosen and thin mucus in the client’s airway. Another use of acetylcysteine is treatment of acetaminophen overdose. Nevertheless, removing acetaminophen from the medication administration record is not the priority action since there is no evidence of overdose.

Overview

Acetylcysteine is administered to clients in acute respiratory distress syndrome to loosen secretions in the airway. Suctioning excess secretions is an appropriate action by nursing.

Explanation

Learning Outcomes

Acetylcysteine is a mucolytic when used by mouth, it helps thin and loosen mucus in the client’s airway. It is most often used in clients with lung conditions such as pneumonia, emphysema, and acute respiratory distress syndrome. As the mucus is loosened, it needs to be suctioned so as to not go back into the airway and cause decrease in oxygen exchange.

Test Taking Tip

Remember that the airway is priority when choosing what to do first. If the airway is not made a priority, nothing else matters.

Video Rationale