The nurse notes a client with a prescription for glipizide is confused, diaphoretic, and tachycardic. What is the nurse’s priority assessment?

Blood glucose

Apical heart rate

INR level

Last bowel movement

Answer and Explanation

The Correct Answer is A

Choice A reason: This choice is correct because blood glucose is the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. Glipizide is a medicine that lowers blood sugar levels in the body. It can cause side effects such as anxiety, diarrhea, nausea, and low blood sugar. Low blood sugar (hypoglycemia) can cause confusion, sweating, fast heart rate, dizziness, hunger, and seizures. The nurse should check the client's blood glucose level and treat hypoglycemia as soon as possible.

Choice B reason: This choice is incorrect because apical heart rate is not the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. Apical heart rate is the number of heartbeats per minute that can be heard at the apex of the heart. It can be affected by many factors, such as age, activity, stress, and medication. Tachycardia is a condition where the heart beats faster than normal, which can be a sign of low blood sugar, dehydration, infection, or heart problems. The nurse should check the apical heart rate after assessing and treating the blood glucose level.

Choice C reason: This choice is incorrect because INR level is not the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. INR stands for international normalized ratio, which is a measure of how long it takes the blood to clot. It is used to monitor the effect of anticoagulant drugs, such as warfarin, that prevent blood clots. Glipizide does not affect the INR level, and the client's symptoms are not related to bleeding or clotting. The nurse should check the INR level only if the client is taking anticoagulant drugs and has signs of bleeding or clotting.

Choice D reason: This choice is incorrect because the last bowel movement is not the priority assessment for a client with a prescription for glipizide who is confused, diaphoretic, and tachycardic. The last bowel movement is the time and nature of the client's most recent defecation. It can be affected by many factors, such as diet, fluid intake, activity, medication, and bowel habits. Glipizide can cause diarrhea or constipation, which can affect the frequency and consistency of the bowel movement. The nurse should check the last bowel movement after assessing and treating the blood glucose level.

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Free Nursing Study Resources

Correct Answer is ["25"]

Explanation

To calculate the IV flow rate in drops per minute (gtt/min) for the administration of clindamycin, we can follow these steps:

First, we need to determine the total number of minutes for the infusion, which is given as 1 hour:

1 hour × 60 minutes/hour = 60 minutes

Next, we calculate the total number of drops needed for the infusion:

The total volume to be infused is 100 mL.

The drop factor is 15 gtt/mL.

100 mL × 15 gtt/mL = 1500 gtt

Calculate the IV flow rate in drops per minute:

1500 gtt ÷ 60 min = 25 gtt/min

Rounding to the nearest whole number, the nurse should set the IV flow rate to deliver 25 gtt/min.

A. Use soft bristled tooth brush B. Report black or bloody bowel movements C. Limit all fruits and vegetables D. Report coffee ground or bloody emesis E. Shave with electric razor instead of razor blade

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: Using a soft bristled tooth brush can prevent gum bleeding and irritation that may occur with a hard bristled tooth brush. Gum bleeding can be a sign of excessive anticoagulation and increased risk of bleeding.

Choice B reason: Reporting black or bloody bowel movements is important because it can indicate gastrointestinal bleeding, which can be a serious complication of warfarin therapy. Gastrointestinal bleeding can cause anemia, shock, and even death if not treated promptly.

Choice C reason: Limiting all fruits and vegetables is not necessary for a client taking warfarin. However, some fruits and vegetables, especially those that are high in vitamin K, can interfere with the effect of warfarin and increase the risk of clotting. Vitamin K is found in green leafy vegetables, such as spinach, kale, broccoli, and cabbage, and some fruits, such as avocado, kiwi, and grapes. The client should maintain a consistent intake of vitamin K and avoid sudden changes in their diet.

Choice D reason: Reporting coffee ground or bloody emesis is also important because it can indicate upper gastrointestinal bleeding, which can be another serious complication of warfarin therapy. Upper gastrointestinal bleeding can cause hematemesis, melena, anemia, and hypovolemic shock.

Choice E reason: Shaving with an electric razor instead of a razor blade can prevent skin cuts and bleeding that may occur with a razor blade. Skin cuts and bleeding can be a sign of excessive anticoagulation and increased risk of bleeding.

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The nurse notes a client with a prescription for glipizide is confused, diaphoretic, and tachycardic. What is the nurse’s priority assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["25"]

Explanation

Which of the following would be included in bleeding precautions for a client taking warfarin? SELECT ALL THAT APPLY

Correct Answer is ["A","B","D","E"]

Explanation

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