Exhibits

Review H and P, nurse's notes, flow sheet, and prescriptions.

Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have only one option selected.

Reported slight rectal burning sensation

Large, soft stool

Dizziness

Pain level of 3 on a 0 to 10 pain scale

600ml of urine

Abdomen soft and flat

Respiratory rate 13 breaths/min

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"C"},"G":{"answers":"C"}}

The reported slight rectal burning sensation after the administration of a bisacodyl suppository is likely a non-therapeutic side effect. This sensation is a common reaction to rectal medication administration and not directly related to the therapeutic effects of lactulose.
A large, soft stool can be considered a therapeutic result of lactulose, which is often prescribed as a laxative to treat constipation. Its effectiveness is indicated by the production of soft stools.
Dizziness experienced by the patient after requesting to use the restroom could be an unrelated finding or a non-therapeutic side effect. Given that morphine was administered, which can cause dizziness as a side effect, it is important to consider all medications and their interactions when assessing this symptom.
A pain level of 3 on a 0 to 10 pain scale is an unrelated finding concerning the administration of lactulose. Pain assessment is subjective and can be influenced by various factors unrelated to lactulose treatment.
The voiding of 600ml of urine is an unrelated finding to the lactulose treatment. Urine output is influenced by many factors, including fluid intake and other medications.
An abdomen that is soft and flat is an unrelated finding to the lactulose treatment. This is a normal physical examination finding and does not directly correlate with the administration of lactulose.
A respiratory rate of 13 breaths/min is also an unrelated finding to the lactulose treatment. The normal respiratory rate for an adult is typically between 12 to 20 breaths per minute.

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Correct Answer is B

Explanation

A. Rivastigmine is used to improve cognitive function in Alzheimer's disease and not specifically to promote sleep, so suggesting a medication change is not appropriate without further assessment.
B. Insomnia can be a side effect of rivastigmine, especially when starting the medication. It is often temporary and should improve as the body adjusts.
C. Withholding the medication or changing the dosage without guidance from the healthcare provider could impact the client's cognitive function and should not be done based on a single side effect.
D. Increasing the dosage of rivastigmine is not a solution for insomnia and could potentially exacerbate other side effects.

A. Monitor vital signs continuously B. Echocardiogram C. Assess rash D. Administer antihistamine E. Assess lung sounds F. Provide calm environment G. Provide warmth H. Defibrillator at bedside I. Administer steroid J. IV fluids K. Pain medication L. Chest x-ray

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

Explanation

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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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

Exhibits Review H and P, nurse's notes, flow sheet, and prescriptions. Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have only one option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a home visit, the nurse assesses a client with Alzheimer's disease who recently started a new prescription for rivastigmine. The caregiver reports that the client seems to be thinking more clearly but is not sleeping well at night. Which action should the nurse take?

Correct Answer is B

Explanation

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

Explanation

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?

A client with cystitis receives a prescription for phenazopyridine. Which information should the nurse explain to the client about its therapeutic effect?

A client with a history of smoking cigarettes for many years arrives at the clinic and expresses a desire to stop smoking. The client receives a prescription for bupropion to reduce nicotine cravings. Which information should the nurse include in the discharge teaching?

Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Click to mark whether the assessment finding represents a therapeutic result of the minoxidil administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have one option selected.

When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. Which action should the nurse take?

Levothyroxine sodium is prescribed for a client with hypothyroidism. The nurse should instruct the client to report which symptom because it indicates that the client is taking too much levothyroxine sodium?

A client is receiving tamsulosin, an alpha-adrenergic blocking agent, for the management of urinary retention due to benign prostatic hyperplasia (BPH). Which instruction is most important for the nurse to provide?

Exhibits

Review H and P, nurse's notes, flow sheet, and prescriptions.

Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have only one option selected.