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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A reason:

While some herbal preparations may have a placebo effect, echinacea has been shown to have active properties that can aid in the treatment of infections. Echinacea contains compounds that boost the immune system and have anti-inflammatory effects, which can help in the healing process of canker sores.

Choice B reason:

Topical echinacea is not typically used to soothe burns, and there is no evidence to suggest it causes damage to the skin. In fact, echinacea is often used in topical preparations to treat skin conditions due to its anti-inflammatory and antimicrobial properties.

Choice C reason:

Echinacea has been found to be useful in treating some infections, including canker sores. Its immune-boosting and wound-healing properties can help reduce the duration and severity of canker sores. This makes it a beneficial herbal remedy for such conditions.

Choice D reason:

While echinacea is generally considered safe and harmless, it is not accurate to say it is not beneficial in treating skin infections. Echinacea has been used traditionally to treat various skin conditions and infections due to its antimicrobial and anti-inflammatory effects.

A. Provide a PRN NSAID for gum discomfort. B. Obtain a soft bristle toothbrush for the client. C. Review most recent coagulation lab values. D. Complete a medication variance report. E. Report findings to the healthcare provider.

Correct Answer is ["B"]

Explanation

Choice A Reason:

Providing a PRN NSAID for gum discomfort is not advisable in this situation. NSAIDs can increase the risk of bleeding, which is already a concern for a client on anticoagulants. Therefore, this action could exacerbate the client’s condition and should be avoided.

Choice B Reason:

Obtaining a soft bristle toothbrush for the client is a good practice to help minimize gum irritation and bleeding. Soft bristle toothbrushes are gentler on the gums and can help prevent further bleeding and discomfort, making this a suitable action for the nurse to implement.

Choice C Reason:

Reviewing the most recent coagulation lab values is crucial in this scenario. Coagulation tests, such as INR (International Normalized Ratio) or aPTT (activated partial thromboplastin time), can help determine if the anticoagulant dosage is appropriate or if adjustments are needed. This step is essential to ensure the client’s safety and effective management of their anticoagulation therapy.

Choice D Reason:

Completing a medication variance report is not immediately necessary unless there is evidence of a medication error. The priority should be to address the client’s symptoms and ensure their safety. While documentation is important, it should not take precedence over direct patient care in this situation.

Choice E Reason:

Reporting findings to the healthcare provider is essential. The development of bleeding and new bruises indicates a potential adverse reaction to the anticoagulant. The healthcare provider needs to be informed to assess the situation, possibly adjust the medication, and provide further instructions for managing the client’s condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

After receiving the third dose of a new oral anticoagulant prescription, an older adult client develops bleeding and tender gums and has many new bruises. Which actions should the nurse implement? Select all that apply.

Correct Answer is ["B"]

Explanation

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