Nokea
A nurse is caring for a client who has a prescription for amoxicillin. Which of the following findings indicates the client is experiencing an allergic reaction?
- A. Nausea
- B. Cardiac dysrhythmia
- C. Laryngeal edema
- D. Insomnia
Correct Answer: C
Rationale: The correct answer is C: Laryngeal edema. Laryngeal edema is a severe allergic reaction symptom that can lead to airway obstruction and respiratory distress. This is a life-threatening condition that requires immediate intervention. Nausea (A) and insomnia (D) are common side effects of amoxicillin but not indicative of an allergic reaction. Cardiac dysrhythmia (B) is not a typical allergic reaction symptom to amoxicillin.
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A nurse is caring for a client who is in shock and is receiving an infusion of albumin. Which of the following findings should the nurse expect?
- A. Oxygen saturation 96%
- B. PaCO2 30 mm Hg
- C. Increase in BP
- D. Decrease in protein
Correct Answer: C
Rationale: The correct answer is C: Increase in BP. Albumin is a colloid solution that helps increase blood volume and subsequently improves blood pressure in shock patients. Increasing blood volume leads to an increase in blood pressure. Option A is incorrect because oxygen saturation is not directly affected by albumin infusion. Option B is incorrect because a low PaCO2 level is not a direct effect of albumin infusion. Option D is incorrect because albumin is a protein and its infusion would not lead to a decrease in protein levels.
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion.
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
- D. Obtain the first unit of packed RBCs from the blood bank.
- E. Start an IV bolus of lactated Ringer's solution.
Correct Answer: B
Rationale: [0, 1, 0, 0]
The correct answer is Stay with the client for the first 15 min of the transfusion. This action is indicated to monitor for adverse reactions such as fever, chills, or signs of hemolysis. Documenting the blood product transfusion (A) is important but not a priority during the initial phase. Titrating the infusion rate (C) and obtaining the blood product (D) are essential, but staying with the client for monitoring takes precedence. Starting an IV bolus (E) is not related to blood transfusion monitoring.
Complete the following sentence by using the lists of options. Upon analyzing the assessment findings, the nurse identifies that the client is at risk for Select... due to the Select...
- A. concurrent medication use
- B. recent illness
- C. activity level
Correct Answer: A
Rationale: The correct answer is A: concurrent medication use. The nurse identifies the client is at risk for adverse drug interactions or side effects due to the potential interactions between medications. Recent illness (B) may impact the client's health but does not specifically relate to medication use. Activity level (C) is important but does not directly indicate medication risk. Without options D, E, F, and G, they cannot be considered as potential correct choices.
A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol, characterized by symptoms similar to Parkinson's disease. A shuffling gait, which is a slow, dragging walk with short steps and reduced arm swing, is a classic manifestation. Serpentine limb movement (A) is not associated with pseudoparkinsonism. Nonreactive pupils (C) are not a typical symptom of pseudoparkinsonism. Smacking lips (D) is a sign of tardive dyskinesia, another side effect of antipsychotic medications.
A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?
- A. Apply firm pressure to the injection site following administration
- B. Administer the medication into the client's muscle
- C. Expel the air bubble from the syringe prior to injection
- D. Insert the syringe needle halfway into the client's skin
Correct Answer: A
Rationale: Correct Answer: A: Apply firm pressure to the injection site following administration.
Rationale: Applying firm pressure to the injection site following administration of enoxaparin helps minimize the risk of bleeding, as enoxaparin is an anticoagulant medication. This pressure promotes clot formation and reduces the likelihood of bruising or hematoma formation at the injection site.
Summary of other choices:
B: Administer the medication into the client's muscle - Incorrect. Enoxaparin is a subcutaneous medication, not meant for intramuscular administration.
C: Expel the air bubble from the syringe prior to injection - Good practice but not directly related to the administration of enoxaparin.
D: Insert the syringe needle halfway into the client's skin - Incorrect. The needle should be fully inserted for proper subcutaneous injection.