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The nurse is assessing the client to update the plan of care.Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. "The nurse determines that the client's is experiencing -----------, and the blood pressure changes are the result of-------------------.
- A. Adverse drug reaction
- B. Antibiotic
- C. Syncope
- D. Heart failure
- E. IV infiltration
Correct Answer: A,B
Rationale: The client’s symptoms (dizziness, hives, etc.) indicate an adverse reaction (Red Man Syndrome) to vancomycin, causing hypotension. Both blanks are correctly filled by 'Adverse drug reaction' and 'Antibiotic' (vancomycin).
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An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HTN), is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments should the nurse include in evaluating the effectiveness of the medications? (Select all that apply.)
- A. Bowel sounds.
- B. Daily weight.
- C. Heart sounds.
- D. Blood pressure.
- E. Range of motion.
Correct Answer: B,C,D
Rationale: B: Daily weight monitors fluid retention (furosemide effectiveness). C: Heart sounds assess heart failure control (atenolol, enalapril). D: Blood pressure evaluates hypertension management (atenolol, enalapril). Bowel sounds and range of motion are unrelated to these medications’ effects.
It is 1800, and the client has a scheduled dose of insulin glargine due. The client has a regular diet tray ordered with 60 carbohydrates. The tray has not yet arrived in the room. For each nursing action below, click to specify if the action is indicated, contraindicated or nonessential.Each row must have one option selected.
- A. Give insulin lispro 4 units: Contraindicated
- B. Verify that the client can count carbohydrates: Nonessential
- C. Mix the insulin lispro and insulin glargine in one syringe: Contraindicated
- D. Give insulin glargine 12 units: Indicated
Correct Answer:
Rationale: A: Lispro is contraindicated without meal intake to avoid hypoglycemia. B: Carb counting is nonessential for scheduled glargine. C: Mixing lispro and glargine is contraindicated. D: Glargine is indicated as scheduled.
Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions.Click to mark whether the assessment finding represents a therapeutic result of the mannitol administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.
- A. Peripheral edema: Non-therapeutic side effect
- B. Potassium 2.9: Non-therapeutic side effect
- C. Urine output 280 ml: Therapeutic result
- D. Heart rate 79: Unrelated finding
- E. Intracranial pressure 11mmHg: Therapeutic result
- F. Oxygen saturation: Unrelated finding
Correct Answer:
Rationale: A: Edema is a mannitol side effect. B: Hypokalemia is a side effect. C: Increased urine output is therapeutic. D: Normal heart rate is unrelated. E: Reduced intracranial pressure is therapeutic. F: Normal oxygen saturation is unrelated.
According to the information gathered in the nurse's assessment, the nurse should prepare to give the client [Dropdown 1] and [Dropdown 2].
- A. Insulin glargine
- B. A snack
- C. Glucagon
- D. Ceftriaxone
- E. Juice
- F. A glass of Water
Correct Answer: A,B
Rationale: A blood glucose of 279 mg/dL requires insulin glargine for correction, and a snack prevents hypoglycemia post-insulin.
A client is receiving miotics for the treatment of open-angle glaucoma. The nurse determines that a priority nursing problem is 'risk for injury.' This nursing problem is based on which etiology?
- A. Increased frequency of lacrimation.
- B. Decreased night vision.
- C. Increased sensitivity to light.
- D. Diminished color perception.
Correct Answer: B
Rationale: Miotics constrict the pupil, reducing night vision and increasing injury risk in low-light conditions. Lacrimation, photophobia, and color perception changes are less directly linked to injury risk.