Patient Data

Exhibits

Review H and P, and nurse’s note. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Choice A: Place the client on a cardiorespiratory monitor

Reason: Placing the client on a cardiorespiratory monitor is crucial in this scenario because the client is experiencing heart palpitations, dizziness, and lightheadedness, which are indicative of a potential tachydysrhythmia. A cardiorespiratory monitor will continuously track the heart rate and rhythm, allowing for immediate detection of any abnormal heart rhythms. This is essential for timely intervention and management of any life-threatening arrhythmias. Continuous monitoring also helps in assessing the effectiveness of any treatments administered and in making necessary adjustments.

Choice B: Administer diphenhydramine

Reason: Diphenhydramine is an antihistamine commonly used to treat allergic reactions and symptoms of anaphylaxis. However, in this case, the client does not exhibit symptoms of an allergic reaction or anaphylaxis, such as hives, swelling, or difficulty breathing. The primary concern here is the heart palpitations and dizziness, which are more indicative of a cardiac issue rather than an allergic reaction. Therefore, administering diphenhydramine would not address the underlying problem and is not the appropriate action in this scenario.

Choice C: Give a dose of albuterol

Reason: Albuterol is a bronchodilator used to relieve bronchospasm in conditions like asthma. Although the client has moderate persistent asthma and has been using albuterol, the current symptoms of heart palpitations and dizziness suggest a possible overuse of albuterol, leading to tachydysrhythmia. However, in the context of an acute asthma exacerbation, administering albuterol can still be necessary to manage bronchospasm. It is important to balance the need for bronchodilation with the risk of exacerbating tachydysrhythmia. Therefore, giving a dose of albuterol should be carefully considered and monitored.

Choice D: Anaphylaxis

Reason: Anaphylaxis is a severe, life-threatening allergic reaction that requires immediate treatment with epinephrine. The client does not present with symptoms typical of anaphylaxis, such as hives, swelling, or difficulty breathing. Instead, the symptoms of heart palpitations, dizziness, and lightheadedness are more consistent with a cardiac issue. Additionally, the client’s oxygen saturation is 99% on room air, which is not indicative of anaphylaxis. Therefore, anaphylaxis is not the most likely condition in this scenario.

Choice E: Tachydysrhythmia

Reason: Tachydysrhythmia refers to an abnormal heart rhythm with a rapid rate, which can cause symptoms such as heart palpitations, dizziness, and lightheadedness. The client’s symptoms, along with the history of using multiple doses of albuterol, suggest that she may be experiencing a tachydysrhythmia. Albuterol, a beta-agonist, can cause tachycardia and palpitations, especially when used frequently. Therefore, tachydysrhythmia is the most likely condition the client is experiencing.

Choice F: Anemia

Reason: Anemia is a condition characterized by a deficiency of red blood cells or hemoglobin, leading to symptoms such as fatigue, weakness, and dizziness. While dizziness and lightheadedness can be symptoms of anemia, the client’s presentation of heart palpitations and the context of asthma management with frequent albuterol use point more towards a cardiac issue rather than anemia. Additionally, there is no mention of other common symptoms of anemia, such as pallor or fatigue, in the client’s history and physical examination.

Choice G: Breath sounds

Reason: Monitoring breath sounds is essential in assessing the respiratory status of a client with asthma. Changes in breath sounds can indicate the presence of bronchospasm, airway obstruction, or other respiratory complications. In this scenario, monitoring breath sounds will help assess the effectiveness of albuterol treatment and detect any worsening of asthma symptoms. It is also important to ensure that the client’s respiratory status remains stable while addressing the cardiac issue.

Choice H: Airway edema

Reason: Monitoring for airway edema is important in clients with asthma, as it can indicate inflammation and swelling of the airways, leading to obstruction and difficulty breathing. In this case, while the primary concern is the cardiac symptoms, it is still important to monitor for any signs of airway edema, especially given the client’s history of asthma and recent exacerbation of symptoms. This will help in managing the respiratory aspect of the client’s condition and ensuring comprehensive care.

Choice I: Iron level

Reason: Monitoring iron levels is relevant in the context of anemia, as low iron levels can indicate iron deficiency anemia. However, in this scenario, the client’s symptoms and history do not suggest anemia as the primary issue. The focus should be on monitoring parameters related to the cardiac and respiratory systems, given the client’s presentation of heart palpitations, dizziness, and asthma exacerbation. Therefore, monitoring iron levels is not a priority in this case.

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Free Nursing Study Resources

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

Explanation

Choice A reason:

Lisinopril is an ACE inhibitor that is commonly prescribed for once-daily dosing. It is effective in managing hypertension and heart failure with a single daily dose, making it convenient for patients who may have difficulty remembering multiple doses12.

Choice B reason:

Quinapril can also be administered once daily. It is used to treat hypertension and heart failure, and its long half-life allows for effective blood pressure control with a single daily dose

Choice C reason:

Ramipril is another ACE inhibitor that can be given once daily. It is used for hypertension, heart failure, and to reduce the risk of cardiovascular events. Its pharmacokinetics support once-daily dosing, which helps improve patient adherence.

Choice D reason:

Captopril is typically not given once daily due to its shorter half-life. It usually requires multiple doses throughout the day to maintain effective blood pressure control.

Choice E reason:

Trandolapril is an ACE inhibitor that can be administered once daily. It is used for hypertension and heart failure, and its long duration of action supports once-daily dosing.

A. Shaking is lessened. B. Client is no longer flushed. C. No longer itching. D. Anxiety has decreased. E. Skin warm and dry. F. Heart rate 62 beats/minute, blood pressure 130/72 mm Hg. G. No chest pain noted H. Respirations are even and unlabored I. Drowsy

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

Explanation

Choice A reason:

Shaking is lessened: This indicates that the client’s nervous system is stabilizing. Shaking or tremors can be a sign of an adverse drug reaction, particularly if the reaction involves the central nervous system. The lessening of shaking suggests that the adverse effects are subsiding and the client’s condition is improving.

Choice B reason:

Client is no longer flushed: Flushing is a common symptom of an adverse drug reaction, particularly with medications like vancomycin, which can cause “red man syndrome.” The absence of flushing indicates that the reaction is resolving and the client’s skin is returning to its normal state.

Choice C reason:

No longer itching: Itching is a common symptom of an allergic reaction. The cessation of itching suggests that the histamine response is diminishing, indicating that the adverse reaction is being controlled and the client is recovering.

Choice D reason:

Anxiety has decreased: Anxiety can be a symptom of an adverse drug reaction, particularly if the reaction involves the cardiovascular or nervous system. The decrease in anxiety indicates that the client’s overall condition is stabilizing and that the adverse effects are subsiding.

Choice E reason:

Skin warm and dry: Normal skin temperature and moisture levels indicate that the client’s autonomic nervous system is functioning properly. This is a positive sign that the adverse drug reaction is resolving and the client’s body is returning to its normal state.

Choice F reason:

Heart rate 62 beats/minute, blood pressure 130/72 mm Hg: These vital signs are within normal ranges for a resting adult. A normal heart rate (60-100 beats per minute) and blood pressure (less than 120/80 mm Hg) indicate that the client’s cardiovascular system is stabilizing and that the adverse drug reaction is resolving.

Choice G reason:

No chest pain noted: The absence of chest pain is a positive sign, as chest pain can be a symptom of a severe adverse drug reaction, particularly if it involves the cardiovascular system. The lack of chest pain indicates that the client’s condition is improving.

Choice H reason:

Respirations are even and unlabored: Normal respiratory function indicates that the client’s respiratory system is not being adversely affected by the drug reaction. Even and unlabored respirations suggest that the client is recovering and that the adverse effects are subsiding.

Choice I reason:

Drowsy: While drowsiness can be a side effect of medications like diphenhydramine, it can also indicate that the client’s body is relaxing and recovering from the adverse drug reaction. Drowsiness in this context is a sign that the client is stabilizing and that the adverse effects are being managed.

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Naxlex Comprehensive Predictor Exams

The nurse notifies the healthcare provider (HCP) that the client is having trouble remembering to take his second dose of captopril. What angiotensin-converting enzyme (ACE) inhibitors can be given only once per day? Select all that apply.

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

Explanation

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

Explanation

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