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Exhibits

For each body system, click tanto specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention. Each category must have at least one response option selected.

Body system

Potential nursing intervention

Cardiovascular

Monitor vital signs continuously

Provide warmth

Echocardiogram

Defibrillator at bedside

Immunological

Administer steroid

Assess rash

IV fluids

Administer antihistamine

Respiratory

Assess lung sounds

Pain medication

Provide calm environment

Chest x-ray

Monitor vital signs continuously

Echocardiogram

Assess rash

Administer antihistamine

Assess lung sounds

Provide calm environment

Provide warmth

Defibrillator at bedside

Administer steroid

IV fluids

Pain medication

Chest x-ray

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

Monitor vital signs continuously: This is crucial to detect any further changes in heart rate or blood pressure, especially given the client’s history of symptomatic bradycardia and recent hypotensive episode following vancomycin administration.

Echocardiogram: This is appropriate post-pacemaker insertion to assess cardiac function and ensure the pacemaker is functioning properly.

Immunological:

Administer antihistamine: Given the client’s adverse reaction to vancomycin, which included hives, flushing, and itching, administering an antihistamine like diphenhydramine is appropriate.

Assess rash: Monitoring the progression or improvement of the rash will help evaluate the effectiveness of the interventions and the resolution of the allergic reaction.

Respiratory:

Assess lung sounds: It's important to evaluate the client’s respiratory status, especially given the shortness of breath reported post-operatively, which could indicate a reaction to the medication or a complication from the procedure.

Provide calm environment: This intervention helps in reducing anxiety and stress, which can exacerbate symptoms and impact cardiovascular and respiratory status.

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Correct Answer is B

Explanation

A. pH levels are not directly affected by calcium acetate and do not indicate the medication's effectiveness.
B. Calcium acetate is used to lower phosphate levels in patients with CKD, so a decrease in phosphate indicates that the medication is having the desired effect.
C. Potassium levels are not directly impacted by calcium acetate and do not reflect the medication’s effectiveness in managing phosphate levels.
D. Calcium levels are not the primary target of calcium acetate therapy; the focus is on reducing phosphate levels in CKD management.

A. Ask the client to describe how she takes the medication. B. Remind the client to take the medication with plenty of water. C. Advise the client to go to the nearest emergency department. D. Suggest use of an antacid two hours after the medication.

Correct Answer is A

Explanation

A. Risedronate can cause esophageal irritation and heartburn if not taken properly. It is crucial to assess the client’s method of taking the medication to identify potential issues such as not taking it with enough water or not remaining upright after taking it.
B. While taking the medication with plenty of water is important, understanding the client's current practices helps to identify specific issues.
C. Advising an emergency department visit is not appropriate unless there are severe symptoms indicating an emergency.
D. Antacids should generally be avoided as they can interfere with the absorption of risedronate.

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Body system	Potential nursing intervention
Cardiovascular	Monitor vital signs continuously Provide warmth Echocardiogram Defibrillator at bedside
Immunological	Administer steroid Assess rash IV fluids Administer antihistamine
Respiratory	Assess lung sounds Pain medication Provide calm environment Chest x-ray

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic kidney disease (CKD) is receiving calcium acetate 667 mg PO. A decrease in which blood value indicates to the nurse that the medication is having the desired effect?

Correct Answer is B

Explanation

A female client with osteoporosis has been taking a weekly dose of oral risedronate for several weeks. The client calls the clinic nurse to report increasing "heartburn." How should the nurse respond?

Correct Answer is A

Explanation

A female client who is starting a new prescription for doxycycline hydate tells the nurse that she takes birth control pills. Which action should the nurse take?

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