Nokea
A nurse is assessing a client after administering a prescribed medication. Which of the following would alert the nurse to suspect that the client is developing anaphylactic shock?Select one that does not apply.
- A. Wheezing
- B. Hypertension
- C. Dyspnea
- D. Urticaria
Correct Answer: B
Rationale: The symptoms of anaphylactic shock are dyspnea, feeling of fullness in the throat, cough, wheezing, extremely low blood pressure, tachycardia (heart rate >100 bpm), palpitations, syncope, cardiac arrest, urticaria, angioedema, pruritus, sweating, nausea, vomiting, and abdominal pain.
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Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?
- A. Platelet count
- B. Triglyceride level
- C. Complete blood count
- D. White blood cell count
Correct Answer: B
Rationale: Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. Options 1, 3, and 4 do not need to be monitored specifically during this treatment.
Amiodarone has been prescribed in a patient with a supraventricular dysrhythmia. Patient teaching should include all of the following EXCEPT:
- A. Notify your health-care provider immediately if you have visual change.
- B. Monitor your own blood pressure and pulse daily.
- C. Take a hot shower or bath if you feel dizzy.
- D. Use a sunscreen on exposed body surfaces.
Correct Answer: C
Rationale: Hot showers can worsen amiodarone-induced hypotension, not help it.
Zoster vaccine (Zostavax) is:
- A. A live varicella zoster vaccine from the same strain used to develop the varicella vaccine
- B. Effective in preventing varicella zoster in patients of all ages
- C. Recommended for patients age 40 to 80 who have had chickenpox
- D. Administered at the same time as other live vaccines, as long as they are given the same day
Correct Answer: A
Rationale: Zostavax is a live vaccine from the varicella strain, for adults 50+ (not all ages, B, or 40-80, C); timing with other vaccines has restrictions.
The home health nurse is caring for a 77-year-old patient with congestive heart failure. What would the nurse consider a priority to assess to develop the most effective plan of care related to medication administration?
- A. Description of the patient's living environment
- B. Required lifestyle changes
- C. Family members in the community
- D. Compliance with therapy to reduce risk of skin breakdown
Correct Answer: A
Rationale: Living environment affects medication storage, access, and administration, critical for an elderly patient with CHF.
A 35-year-old male patient is admitted to the hospital with pneumonia. He was originally being treated at home, but became worse when he quit taking his medicine. What would be an appropriate nursing diagnosis for this patient?
- A. Deficient knowledge: monitoring temperature
- B. Noncompliance
- C. Risk for injury related to office visits
- D. Non-adherence: overuse
Correct Answer: B
Rationale: Noncompliance reflects the patient's failure to continue prescribed treatment, worsening his condition.