Nokea
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.
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History and physical
Client is a 66-year-old male with a history of type 2 diabetes mellitus and hypertension. He takes a metoprolol, hydrochlorothiazide, and metformin. He went to his primary healthcare provider reporting that he had been having trouble controlling his blood pressure in the last few days. He has also had a severe headache. Client was a direct admit to the hospital from the primary healthcare provider's office.
Nurses notes
1000
Admitted the client to the medical floor. He informs that he already took his metoprolol,
hydrochlorothiazide, and metformin dose. He says his morning glucose was 111 mg/dL (6.16 mmol/L). Rates his pain as 6 on a 0 to 10 pain scale. Minoxidil and ibuprofen given as prescribed.
1200
Pain rated at 1 on a 0 to 10 pain scale.
Lab results
Blood glucose 218mg/dl
Flowsheet
1000
Vital signs
. Temperature 99° F (37.2° C) orally
. Heart rate 59 beats/minute in atrial fibrillation
• Respiratory rate 20 breaths/minute
. Blood pressure 203/166 mm Hg
Oxygen saturation 97% on room air
Orders
Admit to the medical floor
Heart healthy diet
Vital signs every 2 hours and as needed (PRN)
Give minoxidil 5 mg PO now
Give 400 mg ibuprofen PO PRN for pain
Check blood glucose before meals and at sleep (HS)
Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Click to mark whether the assessment finding represents a therapeutic result of the minoxidil administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have one option selected.
- A. Dizziness while sitting up: Non-therapeutic side effect
- B. Blood glucose 218mg/dl: Unrelated finding
- C. Mouth dryness: Non-therapeutic side effect
- D. Blood pressure 162/111mmHg: Therapeutic result
- E. Heart rate 99: Non-therapeutic side effect
- F. Pain of 1 out of 10: Unrelated finding
- G. Urine output 600ml: Unrelated finding
Correct Answer:
Rationale: A: Dizziness is a minoxidil side effect (hypotension). B: High glucose relates to diabetes. C: Dry mouth is a possible side effect. D: Lowered blood pressure is therapeutic. E: Tachycardia is a side effect. F: Pain reduction relates to ibuprofen. G: Urine output is unrelated.
The nurse is caring for a client with atrial fibrillation who receives a prescription for warfarin. The international normalized ratio (INR) is 2.8. Which action should the nurse take?
- A. Obtain another blood sample.
- B. Give the next scheduled dose.
- C. Monitor for signs of bleeding.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: An INR of 2.8 is within the therapeutic range for atrial fibrillation, but monitoring for bleeding is critical as a routine precaution. Repeating the sample, giving the dose, or notifying the provider are less immediate.
History and physical
The client is a 24-year-old female who was hit by a car while riding her bicycle. She was wearing a helmet, but her head struck the windshield of the vehicle at approximately 40 miles per hour (mph).
Nurses notes
1800
Client is intubated and on a ventilator. Breath sounds clear and equal. Pupils are 3 mm and sluggish. Responds to painful stimuli. Intracranial pressure 12 mm Hg. Pulses 2+ in all extremities. Capillary refill 2 seconds.
1900
Pupils are 3 mm and sluggish. Client is unresponsive to painful stimuli. Intracranial pressure 24 mm Hg. Healthcare provider (HCP) notified of status. Mannitol given as prescribed.
2000
Breath sounds clear and equal. Pupils are 4 mm and sluggish. Now responds to painful stimuli. Intracranial pressure 11 mm Hg. Has some dependent peripheral edema noted.
Flowsheet
Heart rate 79 beats/minute • Respiratory rate 18 breaths/minute
Blood pressure 111/79 mm Hg
Oxygen saturation 99% on ventilator
Orders
Admit to the surgical intensive care unit
Monitor intracranial pressure every hour
Lactated Ringer's 100 mL/hr IV infusion
Vital signs every hour
Neurological check every hour
Complete blood count, blood gas, and chemistry every 4 hours
Imaging
Head CT scan: cerebral edema
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.
A young adult female client who is planning to become pregnant asks the nurse if she can continue taking isotretinoin for cystic acne. Which information is most important for the nurse to provide this client?
- A. Breastfeeding is not recommended while taking this medication.
- B. Do not take multiple vitamins that contain vitamin A while taking this drug.
- C. Baseline liver function results must be obtained during therapy.
- D. Discontinue this medication one month before attempting to conceive.
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, requiring discontinuation at least one month before conception to prevent birth defects. Breastfeeding, vitamin A, and liver monitoring are secondary concerns.
History and physical
The client is a 75-year-old female who was admitted to the preop area to prepare for pacemaker insertion. She states that she needs this procedure because her heart rate has been very low, she feels tired all the time, and she has fainted once due to low heart rate. She has a history of worsening symptomatic bradycardia and atrial fibrillation controlled by medication. She has been off anticoagulants for four days to prepare for the procedure.
Nurses notes
0700
Laboratory specimens have been drawn and completed during a preadmission visit. After changing clothes and settling into bed, client was placed on continuous monitoring. Admission process completed.
0800
Peripheral IV (PIV) started in right antecubital with 20 gauge catheter. IV fluids of 0.9% sodium chloride started at 50 mL/hr. Cardiac surgeon in to see client and answers questions about the procedure.
0830
Client reports no known allergies. Vancomycin 1 gram in 250 ml 0.9% sodium chloride started at 125 mL/hr as endocarditis prophylaxis.
0840
Awaiting transfer to operating room (OR).
Vancomycin infusing at 125 mL/hr.
0845: The client says, "I don't feel well." Assessment reveals dizziness, headache, burning sensation on extremities, and red color on face and extremities. Blood pressure is 108/46 mmHg. Vancomycin infusion was stopped. The surgeon was notified.
0850: The client has flushing and redness over her entire body with hives developing. She complains of feeling hot and nauseous. Cool cloths were applied to her face and extremities. She is restless in bed. IVF of NS is running.
0900
Heart rate 90 beats/minute, blood pressure 110/60 mm Hg. Surgeon remains at bedside.
0915
Heart rate 60 beats/minute, blood pressure 120/70 mm Hg. Appears more relaxed - not thrashing about bed. Skin color remains red: reports itching
resulting in symptoms of skin color0945
Heart rate 52 beats/minute, blood pressure 128/72 mm Hg. To OR for pacemaker placement.
1100
Returned from OR. Heart rate 64 beats/minute, blood pressure 118/68 mm Hg, temperature 97.4° F(36.3° C) orally. Verbalizes not being able to stop shaking and pounding chest pain. Short of breath. Skin color is dark pink. Headache increasing and has nausea. Surgeon at bedside. Chest x-ray done. Echocardiogram performed.
Orders
0800
Start peripheral IV
Vancomycin 1 gram in 250 mL 0.9% sodium chloride
0845
• Stop vancomycin
The nurse is implementing solutions to provide care.
0855
IV diphenhydramine
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).