Patient Data

The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence.

Sentence: The client is at immediate risk for developing:
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E","dropdown-group-3":"E"}

The client is at immediate risk for developing Cardiac arrest, Anaphylaxis, and Arrhythmias.

Choice A: Peripheral Edema

Peripheral edema refers to the swelling of tissues, usually in the lower limbs, due to the accumulation of fluid. While peripheral edema can be a concern in patients with heart conditions, it is not an immediate risk in the context of the patient’s current situation. The primary concerns for this patient, given her history of symptomatic bradycardia and atrial fibrillation, are more acute and life-threatening conditions such as cardiac arrest, anaphylaxis, and arrhythmias. Peripheral edema is typically a chronic condition that develops over time and is not considered an emergent risk in this scenario.

Choice B: Renal Failure

Renal failure, or kidney failure, is a condition where the kidneys lose their ability to filter waste from the blood effectively. While renal failure can be a serious complication, it is not an immediate risk for this patient. The patient’s primary issues are related to her cardiovascular system, specifically her low heart rate and history of atrial fibrillation. The immediate risks in this scenario are more likely to be related to acute cardiovascular events rather than renal complications. Additionally, there is no indication in the patient’s history or current treatment that suggests an imminent risk of renal failure.

Choice C: Necrosis

Necrosis refers to the death of body tissue due to a lack of blood flow or infection. While necrosis can occur in severe cases of prolonged ischemia or infection, it is not an immediate risk for this patient. The patient’s current condition and treatment plan do not indicate a high risk of tissue necrosis. The more pressing concerns are related to her cardiovascular health, specifically the risk of cardiac arrest, anaphylaxis, and arrhythmias. These conditions are more likely to occur suddenly and require immediate medical intervention.

Choice D: Cardiac Arrest

Cardiac arrest is a sudden loss of heart function, leading to a cessation of blood flow to the body’s organs. Given the patient’s history of symptomatic bradycardia and atrial fibrillation, she is at a high risk of developing cardiac arrest. Bradycardia can lead to insufficient blood flow and oxygen delivery to vital organs, potentially resulting in cardiac arrest. Additionally, the stress of the upcoming procedure and the discontinuation of anticoagulants can further increase this risk. Therefore, cardiac arrest is a significant immediate risk for this patient and requires close monitoring and preparedness for emergency intervention.

Choice E: Anaphylaxis

Anaphylaxis is a severe, potentially life-threatening allergic reaction that can occur rapidly. The patient is receiving vancomycin, which is known to cause hypersensitivity reactions, including anaphylaxis, in some individuals. Symptoms of anaphylaxis include difficulty breathing, swelling, hives, and a drop in blood pressure. Given the patient’s current infusion of vancomycin, she is at risk for developing anaphylaxis, which requires immediate medical attention to prevent severe complications or death. The nurse must be vigilant for signs of anaphylaxis and be prepared to administer emergency treatment if necessary.

Choice F: Arrhythmias

Arrhythmias are irregular heartbeats that can range from benign to life-threatening. The patient has a history of atrial fibrillation, a type of arrhythmia, and symptomatic bradycardia, both of which put her at risk for developing further arrhythmias. The stress of the upcoming procedure, changes in medication, and the underlying heart conditions all contribute to the risk of arrhythmias. These irregular heartbeats can lead to decreased cardiac output, syncope, or even progression to more severe arrhythmias like ventricular fibrillation, which can be fatal. Therefore, arrhythmias are an immediate risk for this patient and require continuous cardiac monitoring and readiness to intervene.

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Correct Answer is D

Explanation

Choice A reason:

Asking if the client’s morning voids are dark-colored can help identify potential side effects of carbidopa-levodopa, such as darkened urine, which is a known but harmless side effect. However, this does not directly address the client’s concern about the medication’s effectiveness.

Choice B reason:

Evaluating the client for signs of dyskinesia is important because dyskinesia can be a side effect of long-term carbidopa-levodopa use. However, this step is more relevant after understanding the client’s specific concerns about the medication’s effectiveness.

Choice C reason:

Determining if the client is taking the medication before meals is crucial because food can affect the absorption of carbidopa-levodopa. Taking the medication on an empty stomach can enhance its effectiveness. However, this step should follow a more detailed exploration of the client’s concerns.

Choice D reason:

Exploring what the client means by the drug “is not working” is the most important first step. This allows the nurse to understand the client’s specific issues, whether they are related to symptom management, side effects, or other concerns. This information is essential for tailoring subsequent interventions and providing appropriate education and support.

A. Rinsing the mouth with water should be done after each use. B. To mask the taste of the medication, the inhaler can be used during meals. C. Caffeinated beverages should be limited to two cups per day. D. The inhaler will be used before bed at night.

Correct Answer is A

Explanation

Choice A reason:

Rinsing the mouth with water after using an inhaler, especially one containing corticosteroids, is crucial to prevent oral thrush (a fungal infection) and reduce irritation in the mouth and throat. This practice helps maintain oral hygiene and ensures the medication does not linger in the mouth, which can cause side effects.

Choice B reason:

Using the inhaler during meals to mask the taste of the medication is not recommended. Inhalers should be used as prescribed, and the technique should not be altered to mask the taste. Proper inhaler technique is essential for the medication to reach the lungs effectively.

Choice C reason:

Limiting caffeinated beverages to two cups per day is generally good advice for overall health, but it is not directly related to the use of an inhaler. Caffeine can sometimes exacerbate symptoms of asthma or other respiratory conditions, but this is not a primary instruction for inhaler use.

Choice D reason:

Using the inhaler before bed at night may be part of a prescribed regimen, but it is not a general instruction that indicates understanding of inhaler use. The timing of inhaler use should follow the healthcare provider’s instructions, which may vary depending on the medication and the individual’s condition.

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Patient Data The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence. Sentence: The client is at immediate risk for developing: dropdown , dropdown and dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who was recently diagnosed with Parkinson’s disease and is taking carbidopa-levodopa. The client is concerned that the medication is not working. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

The nurse is teaching a client how to use an inhaler device. Which client statement indicates to the nurse that the client understands the instructions?

Correct Answer is A

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?

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.

A client who is newly diagnosed with diabetes insipidus (DI) is receiving synthetic vasopressin intravenously. Which side effect of vasopressin reported by the client should the nurse report to the healthcare provider?

To control asthma, a client in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system, which provides an inhaled powdered form of these combined medications. Which instruction should the nurse provide to this client’s caregivers?

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 nurse is reviewing the client’s laboratory values. Which serum laboratory value indicates to the nurse that a prescription for atorvastatin is having the desired effect for a client at risk for coronary artery disease?

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?

Patient Data

The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence.

Sentence: The client is at immediate risk for developing:
dropdown
,
dropdown
and
dropdown
.