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Patient Data

Exhibits

The nurse is evaluating the client’s progress and nursing implementations. Bold the words to highlight the findings that would indicate the client has recovered from the adverse drug reaction.

1230: Shaking is lessened. Client is no longer flushed. No longer itching. Anxiety has decreased. Skin warm and dry. Heart rate 62 beats/minute, blood pressure 130/72 mm Hg. No chest pain noted. Respirations are even and unlabored. Drowsy.

Shaking is lessened.

Client is no longer flushed.

No longer itching.

Anxiety has decreased.

Skin warm and dry.

Heart rate 62 beats/minute, blood pressure 130/72 mm Hg.

No chest pain noted

Respirations are even and unlabored

Drowsy

Answer and Explanation

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

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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Free Nursing Study Resources

Correct Answer is ["2"]

Explanation

Step-by-Step Calculation

Step 1: Determine the total units prescribed.

The prescription is for 1.2 million units.

Step 2: Determine the concentration of the available vial.

The vial is labeled “600,000 units/mL.”

Step 3: Calculate the volume to be administered.

Volume to be administered = Total units prescribed ÷ Concentration of the vial
Volume to be administered = 1,200,000 units ÷ 600,000 units/mL

Result: The nurse should administer 2 mL.

A. Use relaxation techniques to reduce excessive anxiety. B. Avoid alcohol and other sedatives while taking the medication. C. Move slowly from a sitting position to a standing position. D. Stop taking the medication if intended effect is not immediate.

Correct Answer is D

Explanation

The correct answer is d. Stop taking the medication if intended effect is not immediate.

Choice A Reason:

Using relaxation techniques to reduce excessive anxiety is a beneficial practice for managing generalized anxiety disorder (GAD). Techniques such as deep breathing, meditation, and progressive muscle relaxation can complement medication therapy and help reduce anxiety symptoms1. This statement does not require additional instruction as it aligns with recommended practices.

Choice B Reason:

Avoiding alcohol and other sedatives while taking lorazepam is crucial. Lorazepam is a benzodiazepine that can cause sedation and depress the central nervous system. Combining it with alcohol or other sedatives can enhance these effects, leading to dangerous levels of sedation, respiratory depression, or even overdose2. This advice is appropriate and does not need further instruction.

Choice C Reason:

Moving slowly from a sitting position to a standing position is important to prevent dizziness or lightheadedness, which can be side effects of lorazepam3. This precaution helps reduce the risk of falls and injuries, making it a suitable recommendation that does not require additional instruction.

Choice D Reason:

Stopping the medication if the intended effect is not immediate requires additional instruction. Lorazepam, like other benzodiazepines, may not produce immediate effects, especially in the context of anxiety management. It is important for clients to understand that medication may take some time to achieve the desired therapeutic effect and that abrupt discontinuation can lead to withdrawal symptoms and a potential rebound in anxiety4. The nurse should instruct the client to follow the prescribed regimen and consult their healthcare provider before making any changes to their medication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for penicillin 1.2 million units IM. The available vial is labeled, “600,000 units/mL.” How many mL should the nurse administer? (Enter numeric value only.)

Correct Answer is ["2"]

Explanation

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?

Correct Answer is D

Explanation

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Patient Data Exhibits The nurse is preparing the client’s plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

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