Nokea
A client with streptococcal pneumonia is receiving penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports itching at the IV site, dizziness, and shortness of breath. What should the nurse do first?
- A. Stop the infusion.
- B. Call the provider.
- C. Elevate the head of the bed.
- D. Auscultate breath sounds.
Correct Answer: A
Rationale: In this scenario, the client is exhibiting signs of anaphylaxis, a severe allergic reaction. The priority action for the nurse is to stop the infusion immediately to prevent further administration of the allergen and worsening symptoms. Once the infusion is stopped, the nurse can then proceed with additional interventions, such as calling the provider, assessing the client's respiratory status, and providing appropriate care as needed.
You may also like to solve these questions
What is the therapeutic use of Phenytoin?
- A. Replacement in hypothyroidism to restore normal hormonal balance
- B. Diminished accumulation of acid in the gastric lumen with lessened gastroesophageal reflux
- C. Diminished seizure activity, termination of ventricular arrhythmias
- D. Prevention of thrombus formation, prevention of extension of existing thrombi
Correct Answer: C
Rationale: Phenytoin is primarily used to diminish seizure activity and is effective in terminating ventricular arrhythmias. It works by stabilizing neuronal membranes, reducing repetitive neuronal firing, and limiting the spread of seizure activity in the brain. While phenytoin does not have a direct role in preventing thrombus formation or extending existing thrombi, it is crucial in managing seizures and certain arrhythmias.
A client with peptic ulcer disease is prescribed sucralfate. Which of the following instructions should the nurse include?
- A. Take sucralfate with meals.
- B. Take sucralfate 1 hr before meals.
- C. Take sucralfate with antacids.
- D. Take sucralfate 2 hours after meals.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is providing teaching to a client who has a new prescription for Metoprolol. Which of the following statements should the nurse include?
- A. This medication may make you feel dizzy at first.
- B. You should avoid foods that are high in fat.
- C. Take the medication in the morning.
- D. You may experience a rapid heart rate while taking this medication.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A patient about to receive a morning dose of digoxin has an apical pulse of 53 beats/min. What will the nurse do next?
- A. Administer the dos
- C. Administer the dose, and notify the prescriber.
- D. Check the radial pulse for 1 full minut
Correct Answer: D
Rationale: A low apical pulse rate of 53 beats/min indicates bradycardia, which is a side effect of digoxin. Before administering digoxin, the nurse should always check the patient's pulse rate. If the apical pulse is below the facility's specified parameters (typically below 60 beats/min), the nurse should withhold the dose and notify the prescriber immediately. Bradycardia can be an indication of digoxin toxicity, which can be potentially life-threatening, so it is crucial to follow the protocol and seek further guidance before administering the medication.
Which statement is accurate concerning the use of aspirin (ASA) to treat pain?
- A. High doses are necessary (1 gram) to achieve anticoagulant effects.
- B. Enteric-coated capsules are available to reduce GI side effects.
- C. Increase consumption of herbs such as garlic and ginger to potentiate the anti-inflammatory effects.
- D. In low doses (325 mg), it significantly reduces inflammation.
Correct Answer: B
Rationale: Aspirin's use for pain involves anti-inflammatory and analgesic properties, but it risks GI irritation. Enteric-coated capsules minimize this by dissolving in the intestine, not the stomach, reducing bleeding risk—an accurate statement. High doses are true for anticoagulation, not pain relief, where lower doses suffice. Herbs like garlic and ginger increase bleeding risk, not inflammation relief, making it dangerous advice. Low doses (choice D, 325 mg) primarily prevent clotting, not significantly reduce inflammation, which requires higher doses. Choice B correctly reflects a practical measure to enhance aspirin's safety profile for pain management.