A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?

Question

a. Administer an albuterol treatment.
b. Notify the Rapid Response Team.
c. Assess the client's peripheral pulses.
d. Obtain blood and sputum cultures.

Answer 1

ANS: B
Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care. An albuterol treatment would not address the client's oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat this client.