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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Correct Answer is C

Explanation

Choice A Reason:

Reports of increased energy levels and decreased fatigue are subjective indicators of improvement in anemia symptoms. While these reports are important and suggest that the client is feeling better, they do not provide objective evidence of the effectiveness of epoetin alfa. Hemoglobin levels are a more precise measure of the medication’s impact on anemia.

Choice B Reason:

A food diary showing increased consumption of iron-rich foods indicates that the client is making dietary changes to support their anemia treatment. However, this does not directly measure the effectiveness of epoetin alfa. The medication’s primary goal is to stimulate red blood cell production, which is best assessed through hemoglobin levels.

Choice C Reason:

An increase in hemoglobin level to 12 g/dL (7.45 mmol/L) is an objective indicator that epoetin alfa is effective. Hemoglobin levels are a direct measure of the red blood cell count and oxygen-carrying capacity of the blood. An increase in hemoglobin levels indicates that the medication is successfully treating the anemia associated with CKD.

Choice D Reason:

Taking concurrent iron therapy without adverse effects is important for overall treatment adherence and minimizing side effects. However, it does not directly indicate the effectiveness of epoetin alfa. The primary measure of effectiveness is the improvement in hemoglobin levels.

A. Inquire about perceived anxiety. B. Determine what time the dose is taken. C. Determine daily caffeine intake. D. Ask about the client’s bedtime routine.

Correct Answer is B

Explanation

Choice A Reason:

Inquiring about perceived anxiety is important because anxiety can contribute to sleep difficulties. However, in the context of a client taking dextroamphetamine-amphetamine, the timing of the medication is more directly related to sleep disturbances. While anxiety should be assessed, it is not the most critical factor in this scenario.

Choice B Reason:

Determining what time the dose is taken is crucial because dextroamphetamine-amphetamine is a stimulant that can interfere with sleep if taken too late in the day. Extended-release formulations are designed to provide a steady release of medication throughout the day, but taking the dose too late can lead to insomnia. Adjusting the timing of the dose can help mitigate sleep disturbances.

Choice C Reason:

Determining daily caffeine intake is relevant because caffeine is a stimulant that can also contribute to sleep difficulties. However, the primary concern in this scenario is the timing of the dextroamphetamine-amphetamine dose. While caffeine intake should be assessed, it is secondary to the medication timing.

Choice D Reason:

Asking about the client’s bedtime routine is important for understanding overall sleep hygiene. Good sleep hygiene practices can help improve sleep quality. However, in this context, the timing of the stimulant medication is more directly related to the reported sleep difficulties. Therefore, while bedtime routine is important, it is not the most critical assessment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with anemia secondary to chronic kidney disease (CKD) started a prescription for epoetin alfa two months ago. Which client finding best indicates that the medication is effective?Reference Range:• Hemoglobin (Hgb): 14 to 18 g/dL (8.7 to 11.2 mmol/L)

Correct Answer is C

Explanation

A client who is taking dextroamphetamine-amphetamine extended-release tablets for attention deficit hyperactivity disorder (ADHD) reports having difficulty sleeping at night. Which assessment is most important for the nurse to obtain?

Correct Answer is B

Explanation

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

A client is receiving orlistat as part of a weight management program. Which ongoing assessment should be included in the plan of care to determine the effectiveness of the medication?

A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client and family that glucagon needs to be administered?

The home health nurse observes that a female client is using a topical preparation that contains echinacea to treat a canker sore. Her husband expresses concern regarding the effectiveness and safety of using herbs. How should the nurse respond?

Edited TextA client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

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.