Nokea
A client has received an overdose of sympathomimetic agents. The nurse should assess the client for which of the following late signs of an overdose? Select all that apply.
- A. Hypotension.
- B. Bradycardia.
- C. Seizures.
- D. Profound pyrexia.
- E. Hypertension.
Correct Answer: C, D, E
Rationale: Sympathomimetic overdose can cause seizures, profound pyrexia (fever), and hypertension due to excessive stimulation of the sympathetic nervous system.
You may also like to solve these questions
A client is prescribed morphine sulfate for postoperative pain. Which side effect should the nurse monitor for?
- A. Hypertension
- B. Tachycardia
- C. Respiratory depression
- D. Diarrhea
Correct Answer: C
Rationale: Morphine, an opioid, can cause respiratory depression, a serious side effect requiring close monitoring to ensure client safety.
Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.
- A. Extremities warm to touch.
- B. Improved respiratory status.
- C. Decreased muscle pain with activity.
- D. Participation in self-care measures.
- E. Lungs clear to auscultation.
Correct Answer: A,C,D
Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.
A client has been defibrillated at 360 joules (monophasic) and the attempts to convert the ventricular fibrillation (VF) were unsuccessful. Based on an evaluation of the situation, the nurse determines that which action is best?
- A. Terminating the resuscitation effort
- B. Preparing for the administration of sodium bicarbonate intravenously
- C. Performing cardiopulmonary resuscitation (CPR) for 5 cycles or about 2 minutes
- D. Performing CPR for 5 minutes, then defibrillating 3 more times at 400 joules
Correct Answer: C
Rationale: Defibrillation is an asynchronous countershock used to terminate pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF). The defibrillator is charged to 120 to 200 joules (biphasic) or 300 joules (monophasic) for 1 countershock from the defibrillator, and then CPR is immediately resumed and continued for 5 cycles or about 2 minutes. The rhythm is reassessed after 2 minutes and if VF or pulseless VT continues, the defibrillator is charged to give a second shock at the same energy level previously used. CPR is resumed after the shock if needed and the life support protocol is continued. There is no information in the question to indicate that life support should be terminated. Sodium bicarbonate may be prescribed but is not the best action. Giving CPR for 5 minutes may not help oxygenation to the brain and myocardium and is not the best action.
Select the electrolyte that is accurately paired with its normal level.
- A. Phosphate: From 0.81 to 1.45 mmol/L.
- B. Chloride: From 60 to 110 mEq/L.
- C. Calcium: From 6.5 - 10.6 mg/dL.
- D. Potassium: From 3.7 to 7.2 mEq/L.
Correct Answer: A
Rationale: Normal phosphate levels are 0.81 to 1.45 mmol/L (2.5 to 4.5 mg/dL), making this the correct pairing.
Your client has been getting total parenteral nutrition for bowel rest for the last four days. During your assessment of the client today, your client tells you that their 'chest hurts'. You assess that the client is also experiencing dyspnea. What is most likely occurring with this client?
- A. Your client may be experiencing a fluid overload.
- B. Your client may be experiencing an embolus.
- C. Your client may be hyperglycemic.
- D. Your client may have an inadvertent pneumothorax.
Correct Answer: B
Rationale: Chest pain and dyspnea in a client receiving TPN suggest a possible embolus, such as a pulmonary embolism, which is a serious complication requiring immediate attention.