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 (sumatriptan).
- A. Do not take more than 200 milligrams of this medication within 24 hours.'
- B. You can take a second dose of this medication at least 2 hours after the initial dose if the headache persists.'
- C. You should discontinue this medication if pregnancy is planned or suspected.'
- D. You might experience a rash on your skin while taking this medication.'
- E. You might experience a feeling of pressure in your chest after taking this medication.'
- F. This medication can cause you to feel tired.'
- G. This medication should start to alleviate the headache within 1 hour.'
Correct Answer: A,B,C,E,F,G
Rationale: The correct statements are A, B, C, E, F, and G. A: Correct dose limit to prevent overdose. B: Advises on timing for second dose if needed. C: Important to stop if pregnancy is planned. E: Chest pressure is a potential side effect. F: Fatigue is a possible side effect. G: Expected time frame for headache relief. These statements cover dosage, timing, potential side effects, pregnancy precautions, and expected outcomes. Other options lack crucial information or provide incorrect guidance, such as D, which mentions a rash that is not a common side effect of sumatriptan.
You may also like to solve these questions
A nurse is reviewing the medication administration record of a client who has a wound infection. The client has prescriptions for cefotetan and an NSAID. The nurse should monitor for which of the following medication interactions?
- A. Bleeding
- B. Dysrhythmias
- C. Dizziness
- D. Jaundice
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Cefotetan is a cephalosporin antibiotic that can increase the risk of bleeding when taken with NSAIDs due to their additive effects on platelet function. The combination can lead to gastrointestinal bleeding or bruising. Dysrhythmias (choice B) are not typically associated with this drug combination. Dizziness (choice C) and jaundice (choice D) are not common interactions with cefotetan and NSAIDs.
A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim-sulfamethoxazole. Which of the following statements by the client should indicate to the nurse that the medication is effective?
- A. My appetite is increased.'
- B. I don't have a headache anymore.'
- C. My voice is no longer hoarse.'
- D. I am feeling more alert.'
Correct Answer: C
Rationale: The correct answer is C: "My voice is no longer hoarse." This statement indicates the effectiveness of diphenhydramine, an antihistamine used to treat allergic reactions. Hoarseness is a common symptom of allergic reactions, so if the client's voice is no longer hoarse, it suggests that the medication has alleviated the allergic response.
A: Increased appetite is not a direct indicator of the effectiveness of diphenhydramine in treating an allergic reaction.
B: Relief from headaches is not a specific symptom related to allergic reactions or a typical indicator of diphenhydramine effectiveness.
D: Feeling more alert is not a direct indicator of the effectiveness of diphenhydramine in treating allergic reactions.
Therefore, option C is the most appropriate choice as it directly relates to the specific symptom of the allergic reaction that diphenhydramine is intended to treat.
A nurse is reinforcing teaching with a client who is to start therapy with furosemide. The nurse determines that the teaching is effective when the client states he will increase intake of which of the following foods?
- A. Oatmeal
- B. Baked potatoes
- C. Brown rice
- D. Eggs
Correct Answer: B
Rationale: The correct answer is B: Baked potatoes. Furosemide is a loop diuretic that can lead to potassium depletion. Baked potatoes are high in potassium, which can help prevent hypokalemia associated with furosemide therapy. Oatmeal, brown rice, and eggs are not particularly high in potassium and would not be the best choice for increasing potassium intake. By choosing baked potatoes, the client can help maintain adequate potassium levels while on furosemide therapy.
A nurse is reinforcing teaching with a client who has COPD and has been taking long-term high doses of prednisone. Which of the following instructions should the nurse include in the teaching?
- A. Limit potassium-containing foods in your diet.'
- B. Withhold prednisone for 48 hours prior to receiving contrast dye.'
- C. Measure your blood glucose levels periodically.'
- D. Take prednisone on an empty stomach.'
Correct Answer: C
Rationale: The correct answer is C: Measure your blood glucose levels periodically. Clients taking long-term high doses of prednisone are at risk for developing steroid-induced diabetes due to the drug's effect on blood glucose levels. Monitoring blood glucose levels will help detect any abnormalities early, allowing for timely intervention.
A: Limiting potassium-containing foods is not directly related to prednisone use in COPD.
B: Withholding prednisone for 48 hours prior to receiving contrast dye can lead to adrenal insufficiency in clients on long-term prednisone therapy.
D: Taking prednisone on an empty stomach is not a specific instruction related to managing COPD or prednisone therapy.
A nurse is collecting data from a client who reports nausea and has vomited clear emesis. Which of the following medications should the nurse administer?
- A. Meperidine
- B. Diazepam
- C. Naloxone
- D. Promethazine
Correct Answer: D
Rationale: The correct answer is D: Promethazine. Promethazine is an antiemetic medication commonly used to treat nausea and vomiting. It works by blocking dopamine receptors in the brain, reducing the feeling of nausea. Meperidine (A) is a pain medication and not indicated for nausea. Diazepam (B) is a benzodiazepine used for anxiety and seizures, not for nausea. Naloxone (C) is an opioid antagonist used for opioid overdose, not for nausea.