A patient is taking a drug that has known toxic side effects. What will the nurse do?
Discontinue the drug at the first signs of toxicity.
Teach the patient how to treat the symptoms if they develop.
Ensure that complete blood counts are ordered periodically.
Monitor the function of all organs potentially affected by the drug.
The Correct Answer is D
Choice A Reason:
Discontinuing the drug at the first signs of toxicity might seem like a straightforward solution, but it is not always the best approach. Some drugs are essential for treating serious conditions, and stopping them abruptly can cause more harm than good. Instead, the nurse should monitor the patient closely and consult with the healthcare provider to adjust the dosage or switch to a safer alternative if necessary.
Choice B Reason:
Teaching the patient how to treat symptoms if they develop is important, but it is not sufficient on its own. While patient education is a crucial aspect of managing drug side effects, it should be part of a broader strategy that includes regular monitoring and medical supervision.
Choice C Reason:
Ensuring that complete blood counts are ordered periodically is a good practice, especially for drugs that can affect blood cells. However, this approach is too narrow. Toxic side effects can impact various organs and systems, so a comprehensive monitoring plan is necessary.
Choice D Reason:
This is the correct answer. Monitoring the function of all organs potentially affected by the drug is the most comprehensive and effective approach. This includes regular blood tests, liver function tests, kidney function tests, and other relevant assessments. By closely monitoring the patient’s organ functions, the healthcare team can detect early signs of toxicity and take appropriate action to prevent serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
The exhaustion stage is the final phase of the general adaptation syndrome (GAS). It occurs when the body has been exposed to stress for a prolonged period and can no longer maintain resistance. Symptoms of exhaustion include fatigue, burnout, depression, and decreased stress tolerance. Since the student is experiencing an immediate response to a sudden stressor, this stage does not apply.
Choice B Reason:
Adaptation is not a specific stage in the general adaptation syndrome. The correct stages are alarm, resistance, and exhaustion. Therefore, this choice is incorrect.
Choice C Reason:
This is the correct answer. The alarm stage is the initial phase of the general adaptation syndrome, also known as the “fight-or-flight” response. During this stage, the body reacts to a stressor by activating the sympathetic nervous system, which leads to increased heart rate, rapid breathing, and heightened alertness. The student’s reaction to the near-miss accident fits this description perfectly.
Choice D Reason:
The stage of resistance is the second phase of the general adaptation syndrome. During this stage, the body attempts to adapt to the stressor and return to a state of balance. If the stressor persists, the body remains on high alert, but the initial shock of the alarm stage has passed. Since the student’s response is immediate and acute, it aligns with the alarm stage rather than the resistance stage.
Correct Answer is B
Explanation
Choice A Reason:
Increased neuromuscular excitability is not typically associated with respiratory acidosis. Instead, respiratory acidosis can lead to symptoms such as confusion, fatigue, and shortness of breath due to the buildup of carbon dioxide in the blood. Neuromuscular excitability is more commonly associated with conditions like hypocalcemia.
Choice B Reason:
This is the correct answer. Respiratory acidosis occurs when the lungs cannot remove enough carbon dioxide (CO2) from the body, leading to an accumulation of CO2 in the blood. This increase in CO2 results in the formation of carbonic acid, which lowers the pH of the blood. The elevated levels of carbonic acid are a hallmark of respiratory acidosis.
Choice C Reason:
Increased pH is not associated with respiratory acidosis. In fact, respiratory acidosis is characterized by a decrease in blood pH due to the accumulation of carbon dioxide and the subsequent increase in carbonic acid. Therefore, this choice is incorrect.
Choice D Reason:
Hypokalemia, or low potassium levels, is not typically associated with respiratory acidosis. Instead, respiratory acidosis can sometimes lead to hyperkalemia (high potassium levels) due to the shift of potassium out of cells in response to the acidotic state. Therefore, this choice is incorrect.
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