The practical nurse (PN) evaluates a client 30 minutes after the initial administration of a new prescription. Which client response requires immediate action by the PN?
Tinnitus and vertigo after taking an aminoglycoside antiinfective.
Pruritus and urticaria after receiving a broad spectrum antibiotic.
Restlessness and excitability after receiving a narcotic analgesic.
Orthostatic hypotension and bradycardia after taking a beta blocker.
The Correct Answer is B
A. Tinnitus and vertigo after taking an aminoglycoside antiinfective: These are signs of ototoxicity, which are serious but typically develop after repeated dosing rather than immediately. Monitoring and reporting are important, but urgent intervention is less critical than acute hypersensitivity reactions.
B. Pruritus and urticaria after receiving a broad-spectrum antibiotic: These symptoms suggest an allergic reaction, which can progress rapidly to anaphylaxis. Immediate assessment, discontinuation of the drug, and notification of the healthcare provider are critical to prevent life-threatening complications.
C. Restlessness and excitability after receiving a narcotic analgesic: Mild restlessness can occur as a side effect, but it is usually not life-threatening. Continuous monitoring is appropriate, but it does not require the same immediate action as an allergic reaction.
D. Orthostatic hypotension and bradycardia after taking a beta blocker: These are known effects of beta blockers and should be monitored. While they may require intervention if severe, they are typically predictable and not immediately life-threatening compared to acute allergic responses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Close the room door to allow the client some quiet and privacy: Providing privacy can be helpful, but in this situation, the client’s withdrawal may indicate anxiety or fear. Simply closing the door does not address the emotional needs that often arise before surgery.
B. Use an open-ended statement to encourage communication: Open-ended statements invite the client to express thoughts and feelings freely, allowing the nurse to assess concerns about the upcoming surgery. This fosters trust, therapeutic communication, and emotional support.
C. Express concern and empathy for the client's loneliness: While showing empathy is important, assuming the client is lonely may not accurately reflect the client’s emotional state. The nurse should first explore what the client is feeling through open-ended conversation.
D. Affirm that facing surgery can be a frightening experience: Offering reassurance without assessing the client’s actual feelings may seem presumptive. It is more therapeutic to first allow the client to verbalize specific fears or concerns before providing reassurance or education.
Correct Answer is D
Explanation
A. Would you like me to call another nurse to be here while I show you the wound?: Offering another nurse does not address the client’s emotional readiness. It may increase anxiety by implying pressure to view the incision before she is prepared to do so emotionally.
B. You will feel better when you see that the incision is not as bad as you may think: This minimizes the client’s feelings and attempts to reassure without validating her emotions. Clients coping with body image changes after mastectomy need empathetic support rather than persuasion.
C. Part of recovery is accepting your new body image, and you will need to look at your incision: Although acceptance is an important part of recovery, this response is too directive and lacks sensitivity. Forcing confrontation with the incision can hinder emotional healing.
D. It’s OK if you don’t want to look or talk about the mastectomy. I will be available when you’re ready: This response acknowledges the client’s current emotional state and gives her control over the timing of her coping process. It conveys empathy, patience, and readiness to provide support when she is emotionally prepared.
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