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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Correct Answer is B

Explanation

A. Promethazine. Promethazine is an antihistamine used to treat nausea, vomiting, and allergic reactions. It does not have antihypertensive properties and does not lower blood pressure. Instead, it has sedative effects and is commonly used for motion sickness or as a preoperative medication.

B. Amlodipine. Amlodipine is a calcium channel blocker that lowers blood pressure by relaxing blood vessels and improving blood flow. It is commonly prescribed for hypertension and angina, as it reduces vascular resistance and decreases the workload on the heart. Clients taking amlodipine should be monitored for hypotension, edema, and dizziness.

C. Fluconazole. Fluconazole is an antifungal medication used to treat fungal infections such as candidiasis. It does not affect blood pressure regulation and is not used for managing hypertension. However, it can interact with certain medications, so monitoring for drug interactions is important.

D. Phenazopyridine. Phenazopyridine is a urinary analgesic used to relieve symptoms of urinary tract infections (UTIs), such as burning and pain during urination. It does not lower blood pressure and has no effect on cardiovascular function. Clients should be advised that this medication can cause orange discoloration of the urine.

A. Fluconazole B. Tetracycline C. Acyclovir D. Cephalexin

Correct Answer is D

Explanation

A. Fluconazole. Fluconazole is an antifungal medication used to treat fungal infections, such as candidiasis. It is not related to penicillin and does not pose a risk for cross-reactivity in clients with a penicillin allergy. It can be safely administered in this scenario.

B. Tetracycline. Tetracycline is a broad-spectrum antibiotic used to treat bacterial infections, including acne and respiratory infections. It belongs to a different antibiotic class than penicillins and cephalosporins, meaning it does not pose a risk of cross-reactivity in clients with a penicillin allergy.

C. Acyclovir. Acyclovir is an antiviral medication used to treat viral infections, such as herpes simplex and varicella-zoster. Since it does not belong to the beta-lactam antibiotic class, it is not contraindicated for clients with a penicillin allergy.

D. Cephalexin. Cephalexin is a first-generation cephalosporin, which shares a similar beta-lactam ring structure with penicillins. Clients with a history of an anaphylactic reaction to penicillin are at increased risk of cross-reactivity with cephalosporins, particularly first-generation ones like cephalexin. Due to the severity of the client’s allergic reaction, cephalexin should be avoided, and an alternative non-beta-lactam antibiotic should be considered.

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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 ......

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medication record of a client who has hypertension. Which of the following medications should the nurse administer to lower the client's blood pressure?

Correct Answer is B

Explanation

A nurse is caring for a client who has cellulitis and is to begin antibiotic therapy. The client has a history of anaphylactic reaction to penicillin. Which of the following medications is contraindicated for this client?

Correct Answer is D

Explanation

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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
.....
.