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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Sucralfate should be taken on an empty stomach, at least 1 hour before meals, to be effective in coating and protecting the gastrointestinal mucosa.
B. Taking sucralfate up to 1 hour after a meal may reduce its effectiveness in coating the stomach lining.
C. Documenting refusal is not appropriate if the medication can be taken later as long as it meets the timing requirements.
D. Sucralfate should not be taken with food as it needs to be administered on an empty stomach to be effective.
Correct Answer is D
Explanation
A. Assessing the client's strength in moving and turning is important for overall care but not specific to the need for a laxative.
B. Observing skin integrity is crucial for preventing pressure ulcers but does not directly relate to the need for a laxative.
C. Evaluating the ability to recognize the urge to defecate is important for understanding bowel habits but less relevant when preparing to administer a laxative.
D. Determining the frequency and consistency of bowel movements is essential to assess the need for a laxative and to monitor its effectiveness.
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