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A client who will be going to surgery states no known allergies to any medications. What is the most important nursing action for the nurse to implement next?
- A. Assess client's knowledge of an allergic response
- B. Record 'no known drug allergies' on the preoperative checklist
- C. Flag 'no known drug allergies' on the front of the chart
- D. Assess client's allergies to non-drug substances
Correct Answer: B
Rationale: The most important action to take in this situation is to record 'no known drug allergies' on the preoperative checklist. This ensures that all healthcare staff involved in the surgery are aware of the client's stated lack of drug allergies, helping to prevent any potential adverse reactions. Assessing the client's knowledge of an allergic response (Choice A) may be valuable but is not the most crucial action at this point. Flagging 'no known drug allergies' on the front of the chart (Choice C) is less practical and visible compared to documenting it on the preoperative checklist. Assessing the client's allergies to non-drug substances (Choice D) is not the priority in this scenario where the focus is on medications due to the upcoming surgery.
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A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?
- A. Increased urinary clearance of the multiple medications has led to diuresis and lowered the blood pressure.
- B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness.
- C. The additive effect of multiple medications has caused the blood pressure to drop too low.
- D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.
Correct Answer: C
Rationale: The correct answer is C. When a client experiences syncope due to a significant drop in blood pressure after receiving multiple antihypertensive medications, the additive effect of these medications can cause the blood pressure to drop excessively. This additive effect can lead to hypotension, which is why the nurse decided to hold the client's scheduled antihypertensive medication. Choices A, B, and D provide incorrect rationales. Choice A mentions diuresis, which is not directly related to the drop in blood pressure due to additive medication effects. Choice B refers to an antagonistic interaction reducing effectiveness, which is not applicable in this scenario. Choice D talks about a synergistic effect leading to drug toxicity, which is not the cause of the sudden drop in blood pressure observed in the client.
The nurse is planning care for a client with end-stage lung cancer. The client expresses concern about ongoing pain management. Which nursing action is most appropriate to include in the plan of care?
- A. Consult the healthcare provider for recommendations on pain management
- B. Schedule the client for physical therapy to manage pain
- C. Recommend the client attend a support group for cancer patients
- D. Suggest alternative therapies like acupuncture or massage
Correct Answer: A
Rationale: Consulting the healthcare provider for recommendations on pain management is the most appropriate action. The healthcare provider can assess the client's pain, prescribe appropriate medications, and adjust the pain management plan as needed. In end-stage cancer, managing pain often requires pharmacological interventions that the healthcare provider can best provide. Physical therapy (choice B) may not be the primary intervention for pain management in end-stage cancer. While attending a support group (choice C) can provide emotional support, it does not directly address the client's pain management concerns. Suggesting alternative therapies (choice D) is not the initial step; consulting the healthcare provider should come first to ensure a comprehensive and tailored pain management plan.
When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)
- A. Protect the medication from light exposure
- B. Monitor for changes in level of consciousness
- C. Observe for onset of generalized bruising or bleeding
- D. Perform ongoing assessment of respiratory status
Correct Answer: D
Rationale: When administering diazepam for a client with alcohol withdrawal symptoms, it is crucial to perform ongoing assessment of respiratory status. Diazepam can lead to respiratory depression, emphasizing the need for continuous monitoring to detect any signs of respiratory distress early. Protecting the medication from light exposure is a general guideline for some drugs but is not a specific concern for diazepam. Observing for bruising or bleeding is not directly associated with the administration of diazepam for alcohol withdrawal symptoms, making choices A and C incorrect.
A client collapses while showering and is found by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next?
- A. Follow the prompts of the AED
- B. Apply the AED pads to the client's chest
- C. Wipe the client's chest dry
- D. Move the client from the bathroom
Correct Answer: B
Rationale: Applying the AED pads is the immediate next step after obtaining the AED in a cardiac arrest situation. Placing the pads correctly on the client's chest is crucial for the AED to analyze the heart rhythm accurately and deliver a shock if needed. Following the prompts of the AED comes after the pads are in place. Wiping the client's chest dry or moving the client from the bathroom are not priorities at this critical moment and may delay life-saving interventions.
The nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and the use of accessory muscles. Which action should the nurse include in the client's plan of care?
- A. Administer the prescribed amiodarone (Cordarone) immediately
- B. Institute a daily fluid restriction while the client is in the hospital
- C. Perform a blood draw for serum Troponin, CK, and CK-MB levels
- D. Place the client in the Trendelenburg position to facilitate perfusion
Correct Answer: A
Rationale: Administering amiodarone is appropriate if arrhythmias are present in the context of pulmonary edema, as it helps manage irregular heart rhythms. In this case, the client is experiencing symptoms related to respiratory distress, and amiodarone can address potential arrhythmias contributing to the condition. Options B and D are not directly related to managing symptoms of pulmonary edema and do not address the underlying cause of the client's distress. Option C, performing blood tests for cardiac enzymes, is important for assessing possible myocardial damage but does not directly address the immediate respiratory distress associated with pulmonary edema.