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A nurse is assisting in the care of a female client.

Complete the following sentence by using the lists of options.

The nurse should first address the client

followed by the client's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

  • Blood pressure. The client's blood pressure dropped from 104/56 mm Hg to 80/46 mm Hg, indicating worsening hypotension. This suggests fluid volume depletion due to ongoing diarrhea and possible sepsis from Clostridium difficile infection. Hypotension is the priority concern as it can lead to shock and organ dysfunction if not addressed immediately. The nurse should anticipate fluid resuscitation with IV fluids to restore circulatory volume.
  • Hgb level. The client's hemoglobin is 17 g/dL, which is elevated compared to normal values (12-16 g/dL). This suggests hemoconcentration, likely due to dehydration from severe diarrhea rather than an actual increase in red blood cell count. While this is concerning, the immediate priority is addressing hypotension before evaluating hemoglobin further.
  • Temperature. The client has a persistent fever of 38.9°C (102°F), which indicates an active Clostridium difficile infection. While fever management is important, hypotension takes priority because it can lead to hypoperfusion and organ failure. Antipyretic medications and infection control measures can be initiated after stabilizing blood pressure.
  • Potassium level. The client's potassium is 3.1 mEq/L, which is below the normal range (3.5-5.0 mEq/L). Diarrhea leads to potassium loss, increasing the risk of cardiac arrhythmias and muscle weakness. After stabilizing the client’s blood pressure, potassium replacement is critical to prevent life-threatening hypokalemia-related complications such as cardiac dysrhythmias.
  • Abdominal findings. The client has a soft, distended abdomen with hyperactive bowel sounds and watery stools with mucus, consistent with Clostridium difficile infection. While these findings confirm the diagnosis, the more urgent issues of hypotension and electrolyte imbalances must be addressed first before further gastrointestinal assessment.
  • Hct level. The hematocrit is elevated (48%), which aligns with hemoconcentration from dehydration. However, fluid resuscitation will help correct this, making it a secondary concern after addressing blood pressure and potassium levels.


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Related Questions

Correct Answer is ["6"]

Explanation

Calculate the total daily dose:

Total daily dose (mg) = Weight (kg) x Dosage (mg/kg/day)

=14.9 kg x 40 mg/kg/day

= 596 mg/day

Calculate the dose per administration (divided into two doses):

Dose per administration (mg) = Total daily dose (mg) / Number of doses

= 596 mg/day / 2 doses

= 298 mg/dose

Calculate the volume to administer per dose:

Volume (mL) = Desired dose (mg) / Available concentration (mg/mL)

Available concentration = 250 mg / 5 mL

= 50 mg/mL

Volume (mL) = 298 mg / 50 mg/mL

= 5.96 mL/dose

Round to the nearest whole number:

5.96 mL is 6 mL/dose

Correct Answer is C

Explanation

A. Tinnitus. Nitrofurantoin is not commonly associated with ototoxicity or tinnitus. Medications such as aminoglycosides and loop diuretics are more likely to cause this adverse effect. While nitrofurantoin can have some neurological side effects, tinnitus is not a primary concern.

B. Abdominal cramping. Gastrointestinal side effects such as nausea and vomiting can occur with nitrofurantoin, especially if taken on an empty stomach. However, abdominal cramping is usually mild and not a serious adverse effect requiring discontinuation of the medication. Taking the drug with food can help reduce gastrointestinal discomfort.

C. Stevens-Johnson syndrome. Stevens-Johnson syndrome (SJS) is a rare but serious hypersensitivity reaction that can occur with nitrofurantoin use. It presents with flu-like symptoms, followed by a painful rash, blistering, and skin peeling. Immediate discontinuation and medical intervention are required if symptoms develop, as SJS can be life-threatening.

D. Insomnia. Nitrofurantoin does not commonly cause insomnia. Some medications, such as corticosteroids and stimulants, are more likely to interfere with sleep. Nitrofurantoin’s side effects primarily affect the gastrointestinal, pulmonary, and dermatologic systems rather than sleep patterns.

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