Nokea
Nurses Notes
Plan of Care
Provider Prescriptions
Vital Signs
Admissions Assessment
6 months ago:
The client was diagnosed with epilepsy during childhood. The client reports not having seizures for 2 years. The client has weaned off all seizure medications. The client was informed to return to the office for a follow-up in 6 months and to call the office if seizure activity resumes
Today:
The client reports having a seizure this morning. Provider aware and new prescription obtained.
Click to highlight the findings that require immediate follow-up as contraindications to the prescribed prescription (phenytoin).
- A. Client is a vegetarian and takes a multivitamin daily
- B. Client reports having three to four alcoholic beverages a couple times per week
- C. Last menstrual period was 3 months ago
- D. Client takes diazepam as needed for anxiety
Correct Answer: A,B,C,D
Rationale: [1,1,1,1]
The correct answer is A, B, C, D.
A: Vegetarian diet may lack sufficient Vitamin K, which interacts with phenytoin.
B: Alcohol increases phenytoin levels, leading to toxicity.
C: Missed periods could indicate pregnancy, a contraindication for phenytoin.
D: Diazepam increases sedation when combined with phenytoin.
Incorrect choices:
E, F, G: These choices do not directly interact with phenytoin or have contraindications.
You may also like to solve these questions
A nurse is preparing to administer phenobarbital 3 mg/kg/day PO in two divided doses to a client who weighs 145 lb. The amount available is phenobarbital 100 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 1
Rationale: To determine the total daily dose, convert the client's weight from lb to kg (145 lb / 2.2 = 65.91 kg). Then calculate the total daily dose in mg (3 mg/kg/day * 65.91 kg = 197.73 mg/day). Since it is divided into two doses, the nurse should administer approximately 99 mg per dose. Since each tablet is 100 mg, the nurse should administer 1 tablet per dose. This is the correct answer, as it ensures the client receives the prescribed dose. Other choices are incorrect as they do not align with the calculated dose needed, leading to potential under or overdosing.
A nurse is preparing to insert a miconazole vaginal suppository for a client who has vulvovaginal candidiasis. Which of the following actions is appropriate for inserting this medication?
- A. Assist the client to a left lateral position.
- B. Insert the suppository along the posterior wall of the vaginal canal
- C. Apply a light coating of petroleum jelly to the suppository.
- D. Put on sterile gloves before handling the suppository.
Correct Answer: B
Rationale: The correct answer is B: Insert the suppository along the posterior wall of the vaginal canal. This is because the posterior wall of the vaginal canal allows for the suppository to be placed in the most effective location for absorption and treatment of the infection. Placing it along this wall ensures proper placement and maximum efficacy of the medication.
Choice A: Assisting the client to a left lateral position is not directly related to the correct technique for inserting the suppository.
Choice C: Applying petroleum jelly to the suppository is not necessary and may interfere with the medication's absorption.
Choice D: Putting on sterile gloves before handling the suppository is not required for this procedure as the suppository is meant to be inserted directly into the vaginal canal.
A nurse is monitoring a client's response to receiving glipizide instead of guaifenesin. Which of the following actions should the nurse take?
- A. Lower the head of the client's bed.
- B. Check the client for urinary retention
- C. Offer the client a carbohydrate snack.
- D. Test the client's deep-tendon reflexes.
Correct Answer: C
Rationale: The correct answer is C: Offer the client a carbohydrate snack. Glipizide is an oral antidiabetic medication that can lower blood sugar levels by stimulating the release of insulin from the pancreas. If the client receives glipizide instead of guaifenesin (an expectorant), there is a risk of hypoglycemia due to the medication's blood sugar-lowering effects. Offering a carbohydrate snack can help prevent or treat hypoglycemia by quickly raising blood sugar levels. Lowering the head of the bed (A), checking for urinary retention (B), and testing deep-tendon reflexes (D) are not directly related to the client's response to glipizide.
A nurse is collecting a medication history from the parent of a preschooler who comes to the clinic for routine immunizations. For which of the following findings should the nurse withhold the varicella immunization?
- A. A pregnant parent
- B. Receiving treatment for leukemia
- C. Taking acetaminophen for mild discomfort
- D. An allergy to eggs
Correct Answer: B
Rationale: The correct answer is B: Receiving treatment for leukemia. This is because individuals with leukemia have weakened immune systems, making them more susceptible to infections. Administering a live vaccine like varicella could potentially cause severe complications in these individuals.
Incorrect choices:
A: A pregnant parent - Pregnancy is not a contraindication for varicella vaccine.
C: Taking acetaminophen for mild discomfort - Acetaminophen does not interfere with varicella vaccine.
D: An allergy to eggs - Varicella vaccine is made using gelatin, not eggs, so egg allergy is not a contraindication.
History and Physical
Medication Administration Record
Vital Signs
1630:
Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields. Diffuse, raised rash present on trunk. Abdomen soft. nontender.
A nurse in the emergency department is assisting in the care of a client.
Click to highlight the findings that require immediate follow-up. To deselect a finding click on the finding again.
Nurses Notes
1630:
Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields, Diffuse, raised rash present on trunk. Abdomen soft, nontender
Vital Signs
1630:
Temperature 38.3°C (101°F)
Heart rate 110/min
Respiratory rate 30/min
Blood pressure 90/55 mmHg
Oxygen saturation 91% on room air
Click to highlight the findings that require immediate follow-up.
- A. Client is short of breath
- B. Intercostal retractions visible
- C. Wheezing auscultated throughout lung fields
- D. Diffuse, raised rash present on trunk
- E. Respiratory rate 30/min
- F. Blood pressure 90/55 mmHg
- G. Oxygen saturation 91% on room air
Correct Answer: A,B,C,D,E,F,G
Rationale: [ , , , , , , ]