Exhibits

The nurse is assessing the client to update the plan of care.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

The nurse determines that the client's is experiencing
dropdown
, and the blood pressure changes are the result of
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Blank 1: Adverse drug reaction: The client’s symptoms of dizziness, headache, burning sensation, redness, flushing, hives, and itching after the administration of vancomycin indicate a severe allergic reaction, likely "Red Man Syndrome," which is an adverse drug reaction.

Blank 2: Antibiotic: The blood pressure changes (initial drop to 108/46 mmHg) are most likely due to the adverse reaction to the vancomycin infusion. The hypotension occurred as a direct result of the antibiotic administration.

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Correct Answer is B

Explanation

A. A metal hip prosthesis does not generally interfere with CT scans or contrast use.
B. Metformin use requires follow-up because contrast agents can affect renal function, potentially increasing the risk of lactic acidosis in clients taking metformin.
C. Sobriety is not directly relevant to the CT scan or contrast administration.
D. The timing of a previous CT scan is not a concern unless it affects contrast use or renal function, which is not indicated here.

A. Obtain another blood sample. B. Give the next scheduled dose. C. Monitor for signs of bleeding. D. Notify the healthcare provider.

Correct Answer is C

Explanation

A. An INR of 2.8 is within the therapeutic range for clients on warfarin, so obtaining another blood sample is not necessary.
B. An INR of 2.8 indicates that the client is within the therapeutic range, so it is appropriate to give the next scheduled dose. However, monitoring for potential bleeding complications is a higher priority.
C. Monitoring for signs of bleeding is crucial because, while an INR of 2.8 is within the therapeutic range, it is still important to watch for any bleeding complications as part of routine care.
D. Notifying the healthcare provider is not immediately necessary unless there are signs of bleeding or other concerns, as an INR of 2.8 is typically within the acceptable range for therapeutic anticoagulation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse?

Correct Answer is B

Explanation

The nurse is caring for a client with atrial fibrillation who receives a prescription for warfarin. The international normalized ratio (INR) is 2.8. Which action should the nurse take?

Correct Answer is C

Explanation

Ferrous sulfate elixir is prescribed for a client with iron deficiency anemia. Which instruction should the nurse provide this client about taking the liquid medication?

Prior to administering an oral dose of methylprednisolone, the nurse determines the client's serum total calcium level is 5.5 mg/dL (1.375 mmol/L). What action is most important for the nurse to 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?

Before administering the initial dose of sumatriptan succinate to a client with a migraine headache, it is most important to determine if the client's history includes which problem?

A client is receiving miotics for the treatment of open-angle glaucoma. The nurse determines that a priority nursing problem is "risk for injury." This nursing problem is based on which etiology?

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client's plan of care?