Patient Data
Review H and P, and nurse’s note. Identify from the choices below 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.
The Correct Answer is []
Potential Condition: Methemoglobinemia
Methemoglobinemia is a condition in which the hemoglobin in the blood is unable to bind oxygen effectively, resulting in tissue hypoxia. It can be caused by exposure to certain drugs or chemicals, such as nitrates, benzocaine, or dapsone. Some symptoms of methemoglobinemia include cyanosis, headache, fatigue, dyspnea, and tachycardia. In severe cases, it can lead to seizures, coma, and death.
Actions to Take:
- Draw blood for a complete blood count
- administer methylene blue
A complete blood count (CBC) can help diagnose methemoglobinemia by measuring the level of methemoglobin in the blood. A normal level is less than 1%, while a level above 15% can cause symptoms. A level above 30% can be life-threatening. Methylene blue is a medication that can reduce methemoglobin back to normal hemoglobin and restore oxygen delivery to the tissues. It is given intravenously at a dose of 1-2 mg/kg over 5 minutes.
Parameters to Monitor:
- Methemoglobin level
- heart rate and rhythm
The methemoglobin level is the most important parameter to monitor in methemoglobinemia, as it indicates the severity of the condition and the response to treatment. The goal is to lower the level below 10% or until symptoms resolve. The heart rate and rhythm are also important to monitor, as methemoglobinemia can cause tachycardia and dysrhythmias due to hypoxia and acidosis. The goal is to maintain a normal sinus rhythm and a heart rate within the normal range for the client’s age and condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Cheese and crackers are not a good snack to take with tetracycline, because cheese contains calcium, which can interfere with the absorption of tetracycline and reduce its effectiveness.
Choice B reason: Toasted wheat bread and jelly are a suitable snack to take with tetracycline, because they do not contain any dairy products or iron, which can also affect the absorption of tetracycline. Toasted bread may also help to settle the stomach and prevent nausea.
Choice C reason: Fruit-flavored yogurt is not a good snack to take with tetracycline, because yogurt is a dairy product that contains calcium, which can interfere with the absorption of tetracycline and reduce its effectiveness.
Choice D reason: Cold cereal with skim milk is not a good snack to take with tetracycline, because skim milk is a dairy product that contains calcium, which can interfere with the absorption of tetracycline and reduce its effectiveness.
Correct Answer is B
Explanation
Choice A reason: Midmorning is not a likely time for experiencing hypoglycemia after administering glargine insulin at 0800, because glargine insulin has a slow onset of action (about 1 hour) and does not have a pronounced peak effect. Glargine insulin is a long-acting insulin that provides a steady level of insulin throughout the day and night.
Choice B reason: No peak occurs is the correct answer for when hypoglycemia is most likely to occur after administering glargine insulin at 0800, because glargine insulin does not have a pronounced peak effect that could cause a sudden drop in blood glucose levels. Glargine insulin is a long-acting insulin that provides a steady level of insulin throughout the day and night.
Choice C reason: Midafternoon is not a likely time for experiencing hypoglycemia after administering glargine insulin at 0800, because glargine insulin has a long duration of action (about 24 hours) and does not have a pronounced peak effect. Glargine insulin is a long-acting insulin that provides a steady level of insulin throughout the day and night.
Choice D reason: Shortly after midnight is not a likely time for experiencing hypoglycemia after administering glargine insulin at 0800, because glargine insulin has a long duration of action (about 24 hours) and does not have a pronounced peak effect. Glargine insulin is a long-acting insulin that provides a steady level of insulin throughout the day and night.
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