A client with systemic lupus erythematosus (SLE) is receiving nonsteroidal anti- inflammatory drug (NSAID) therapy. Which side effect of NSAID therapy should the nurse immediately report to the health care provider?
Melena
Decreased vision
Pancytopenia
Hyperglycemia
The Correct Answer is C
Pancytopenia refers to a decrease in all three major blood cell types: red blood cells (anemia), white blood cells (leukopenia), and platelets (thrombocytopenia). It is a potentially serious side effect that can lead to increased susceptibility to infections, anemia-related symptoms (fatigue, weakness), and an increased risk of bleeding. Prompt reporting is necessary for further
evaluation and appropriate management.
While melena (dark, tarry stools) is a concerning side effect, it typically indicates gastrointestinal bleeding, which should also be reported promptly but may not require immediate action unless the bleeding is severe or accompanied by other symptoms.
Decreased vision can be a side effect of certain medications, including NSAIDs, but it does not usually require immediate reporting unless it is severe or rapidly progressive. Hyperglycemia (high blood sugar) can occur with NSAID therapy, especially in individuals with preexisting diabetes or impaired glucose tolerance. While it should be monitored and managed appropriately, it does not typically require immediate reporting unless it is extremely high or associated with other concerning symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Respiratory acidosis is a primary acid-base imbalance that occurs when there is an excess of carbon dioxide (CO2) in the body due to impaired ventilation or inadequate removal of CO2 from the lungs. In this case, Colleen's depressed ventilation, indicated by shallow and slow respirations, can lead to inadequate elimination of CO2 from her body. The excessive CO2 levels can result in an accumulation of carbonic acid (H2CO3) in the blood, leading to an increase in acidity and a decrease in pH.
The profuse bleeding from both ears indicates a potential head injury, which can lead to decreased neurological function and impaired control over the respiratory center in the brain. This can further contribute to depressed ventilation and the development of respiratory acidosis. Metabolic acidosis, characterized by a decrease in bicarbonate (HCO3-) levels or an increase in non-carbonic acids in the blood, is not the primary acid-base imbalance in this case since the scenario does not provide information indicating a primary metabolic disorder. Respiratory alkalosis, characterized by decreased levels of CO2 in the blood, leading to increased pH and alkalinity, is not the primary acid-base imbalance in this case. The depressed ventilation and associated increase in CO2 levels indicate the opposite, respiratory acidosis. Metabolic alkalosis, characterized by an increase in bicarbonate levels or a decrease in non-carbonic acids, is not the primary acid-base imbalance in this case as the scenario does not provide information indicating a primary metabolic disorder.
Correct Answer is C
Explanation
A low-pressure ventilator alarm indicates a potential issue with the delivery of adequate air or pressure from the ventilator. The pulse oximetry reading of 85% suggests that the client is not receiving sufficient oxygenation.
Providing ventilation with a bag-valve-mask device allows the nurse to manually assist the client's breathing and ensure proper oxygenation and ventilation while troubleshooting the ventilator alarm. By manually ventilating the client, the nurse can help maintain oxygenation and prevent further hypoxemia until the underlying cause of the alarm can be identified and resolved.
Suctioning the client's endotracheal tube, adding air to the pilot balloon, or placing a bit block in the client's mouth may be appropriate interventions in specific situations, but they are not the immediate priority in this case. The primary concern is to address the low oxygen saturation and ensure adequate ventilation.
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