Nokea
Vital Signs
Nurses' Notes
History and Physical
Initial visit:
Temperature 36.5° C (97.7° F)
Heart rate 68/min
Blood pressure 116/70 mm Hg
Respiratory rate 16/min
SpO2 98% on room air
Follow-up visit 2 weeks later:
Temperature 36.7° C (98.1° F)
Heart rate 86/min
Blood pressure 130/80 mm Hg
Respiratory rate 18/min.
SpO2 99% on room air
Select the 6 statements the nurse should include when reinforcing teaching to the client about the newly prescribed medication.
- A. This medication should start to alleviate the headache within 1 hour.
- B. You might experience a feeling of pressure in your chest after taking this medication.
- C. Do not take more than 200 milligrams of this medication within 24 hours.
- D. You can take a second dose of this medication at least 2 hours after the initial dose if the headache persists.
- E. You should discontinue this medication if pregnancy is planned or suspected.
- F. This medication can cause you to feel tired.
- G. You might experience a rash on your skin while taking this medication.
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes statements covering various important aspects of the medication. A: Ensures client knows when to expect relief. B: Alerts to potential side effect. C: Provides clear dosing instructions. D: Instructs on when and how to take a second dose. E: Important for safety during pregnancy. F: Warns about potential side effect. Explanations for incorrect choices: G: Not as crucial as the other statements.
You may also like to solve these questions
A nurse is assisting in the care of a client admitted for an acetaminophen overdose. Which of the following prescriptions should the nurse anticipate implementing?
- A. Administer naloxone.
- B. Monitor amylase and lipase.
- C. Obtain a chest x-ray.
- D. Give acetylcysteine.
Correct Answer: D
Rationale: The correct answer is D: Give acetylcysteine. Acetylcysteine is the antidote for acetaminophen overdose as it helps replenish glutathione stores and prevent liver damage. Naloxone (A) is used for opioid overdose, not acetaminophen. Monitoring amylase and lipase (B) is for pancreatitis, not acetaminophen overdose. Obtaining a chest x-ray (C) is not necessary for acetaminophen overdose. Giving acetylcysteine (D) is the priority intervention for acetaminophen overdose to prevent liver toxicity.
A nurse is evaluating the laboratory results of four clients. The nurse should report which of the following laboratory results to the provider?
- A. A client who has a prescription for heparin and an aPTT of 90 seconds (30-40 seconds).
- B. A client who has a prescription for warfarin and an INR of 2.0 (0.8 to 1.1).
- C. A client who has a prescription for heparin and an aPTT of 65 seconds (30-40 seconds).
- D. A client who has a prescription for warfarin and an INR of 3.0 (0.8 to 1.1).
Correct Answer: A
Rationale: The correct answer is A. A client who has a prescription for heparin and an aPTT of 90 seconds (30-40 seconds) should be reported to the provider because the aPTT result is significantly above the therapeutic range, indicating a potential risk of bleeding due to excessive anticoagulation. Heparin therapy requires close monitoring of aPTT levels to ensure the medication's efficacy and safety. Reporting this result promptly to the provider allows for timely adjustment of the heparin dosage to prevent complications.
Choices B, C, and D are incorrect because they fall within or close to the desired therapeutic ranges for the respective medications. Therefore, they do not require immediate reporting to the provider as they suggest appropriate anticoagulation levels.
A nurse is preparing to administer vaccines to an 11-year-old child who is up to date on immunizations. Which of the following vaccines should the nurse plan to administer?
- A. Quadrivalent human papillomavirus
- B. Rotavirus
- C. Pneumococcal conjugate
- D. Hepatitis B
Correct Answer: A
Rationale: The correct answer is A: Quadrivalent human papillomavirus vaccine. At age 11, the child should receive the HPV vaccine as part of routine immunization. HPV vaccination is recommended for both males and females at this age to prevent HPV-related cancers and diseases. The other options are not typically given to a child who is up to date on immunizations at age 11. Rotavirus vaccine is usually given in infancy, pneumococcal conjugate vaccine is given earlier in childhood, and hepatitis B vaccine is typically administered shortly after birth and during infancy. Therefore, the HPV vaccine is the appropriate choice for this scenario.
A nurse is preparing to administer medication to a client who has a new prescription. Which of the following actions should the nurse take first?
- A. Calculate the correct amount of the medication.
- B. Validate the prescription with the available medication.
- C. Document the time of the medication administration.
- D. Identify the client using two means of identification
Correct Answer: D
Rationale: The correct action for the nurse to take first is to identify the client using two means of identification. This is crucial to ensure the right medication is given to the right patient, preventing errors and ensuring patient safety. By verifying the client's identity, the nurse can confirm they are administering the medication to the correct individual. This step helps prevent medication errors and ensures accountability.
Calculating the correct amount of medication (A) is important but should come after verifying the patient's identity. Validating the prescription with available medication (B) is also important but not the first step. Documenting the time of medication administration (C) is essential but should follow patient identification.
A nurse is collecting data from a client who has been taking carbamazepine. Which of the following is an adverse effect of carbamazepine and should be reported to the provider?
- A. Sore throat
- B. Increased salivation
- C. Urge incontinence
- D. Gingivitis
Correct Answer: A
Rationale: The correct answer is A: Sore throat. Carbamazepine can cause agranulocytosis, a serious condition characterized by a decrease in white blood cells, leading to symptoms like sore throat. This is a potentially life-threatening adverse effect that should be reported to the provider immediately. Increased salivation (choice B), urge incontinence (choice C), and gingivitis (choice D) are not common adverse effects of carbamazepine and do not require immediate reporting.