Nokea
Vital Signs
History and Physical
Assessment
Laboratory Results
Provider Prescriptions
Yesterday:
Temperature 37.4° C (99.3° F)
Heart rate 92/min
Respiratory rate 18/min
Blood pressure 130/82 mm Hg
Oxygen saturation 97% on room air
Today:
Temperature 38.9° C (102° F) Heart rate 110/min
Respiratory rate 18/min
Blood pressure 138/88 mm Hg
Oxygen saturation 96% on room air
The nurse has reviewed the client's electronic medical record (EMR). Which of the following findings should the nurse recommend withholding the ceftriaxone? Select all that apply.
- A. Breastfeeding
- B. Client allergy
- C. Gentamycin prescription
- D. Hematocrit
- E. Hemoglobin
Correct Answer: B,C
Rationale: The correct answers are B and C.
B: Withholding ceftriaxone is recommended if the client has an allergy to it to prevent an allergic reaction.
C: Gentamicin can interact with ceftriaxone, leading to potential adverse effects.
Incorrect choices:
A: Breastfeeding is not a contraindication for ceftriaxone use.
D and E: Hematocrit and hemoglobin levels are not directly related to the administration of ceftriaxone.
You may also like to solve these questions
A nurse is caring for a client who has chronic renal failure and is receiving epoetin alfa. To check for therapeutic effects, the nurse should monitor which of the following client laboratory tests?
- A. Hemoglobin levels
- B. Iron levels
- C. Platelet count
- D. White blood cell count
Correct Answer: A
Rationale: The correct answer is A: Hemoglobin levels. Epoetin alfa stimulates red blood cell production, increasing hemoglobin levels in clients with chronic renal failure who often have anemia. Monitoring hemoglobin levels helps assess the effectiveness of the medication. Iron levels (B) are important for erythropoiesis but not directly affected by epoetin alfa. Platelet count (C) and white blood cell count (D) are not specifically related to the therapeutic effects of epoetin alfa in chronic renal failure.
Nurses' Notes
Vital Signs
Laboratory Results
0800:
Client is admitted with a 3-day history of abdominal cramps and diarrhea of 4 to 5 liquid stools per day.
Client was taking amoxicillin/clavulanate 875 mg PO every 12 hr for 10 days for a respiratory tract infection. Antibiotics completed 7 days ago.
Bilateral breath sounds clear and present throughout.
Abdomen soft, distended with hyperactive bowel sounds audible in all 4 quadrants.
Stool is watery and contains mucous. Stool sent for culture.
A nurse is assisting in the care of a female client.
Complete the following sentence by using the lists of options: The nurse should first address the client ___ followed by the client's ___.
- A. blood pressure
- B. Hgb level
- C. temperature
- D. potassium level
- E. abdominal findings
- F. Hct level
Correct Answer: A,D
Rationale: Sure, here is the detailed explanation for the correct answer :
1. **Blood pressure (A)**: The nurse should first address the client's blood pressure as it is a vital sign that provides immediate information about the client's cardiovascular health and overall perfusion status.
2. **Potassium level (D)**: Following the assessment of blood pressure, addressing the client's potassium level is important as potassium imbalances can have critical implications on cardiac function and require prompt intervention.
**Summary**:
- **Incorrect Choices**:
- B: Hgb level and F: Hct level are related to blood components and not typically the first priority in a general assessment.
- C: Temperature is important but may not be the immediate priority compared to blood pressure and potassium level.
- E: Abdominal findings are important but may not be the initial focus in this context.
- **Correct Choices**:
- A: Blood pressure and D: Potassium level are crucial in
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.
A nurse is preparing to administer medications to a client through an enteral feeding tube. Which of the following interventions is appropriate?
- A. Add the medications to the enteral feeding bag.
- B. Check for gastric residual 15 min after administering the medications
- C. Keep the client's head elevated 15° while administering the medications.
- D. Flush the tube with 30 ml of water between each medication
Correct Answer: D
Rationale: The correct answer is D: Flush the tube with 30 ml of water between each medication. Flushing the tube with water between medications helps prevent clogging and ensures proper medication administration. It also helps prevent interactions between different medications. Adding medications to the feeding bag (choice A) may cause drug interactions or alter the efficacy of the medications. Checking for gastric residual 15 min after administering medications (choice B) is not necessary for enteral tube medication administration. Keeping the client's head elevated 15° (choice C) is important during feeding, but not specifically for medication administration.
A nurse is caring for a client who has Graves' disease and is to start therapy with propylthiouracil. The nurse should expect which of the following outcomes?
- A. Increased Hct
- B. Decreased WBC count
- C. Decreased heart rate
- D. Increased blood pressure
Correct Answer: C
Rationale: The correct answer is C: Decreased heart rate. Propylthiouracil is an antithyroid medication used to treat hyperthyroidism, such as Graves' disease. It works by inhibiting the production of thyroid hormones. A decreased heart rate is an expected outcome as hyperthyroidism can cause tachycardia (increased heart rate), and treatment with propylthiouracil helps normalize heart rate.
Incorrect options:
A: Increased Hct - Propylthiouracil does not affect hematocrit levels.
B: Decreased WBC count - Propylthiouracil does not typically affect white blood cell count.
D: Increased blood pressure - Propylthiouracil does not lead to an increase in blood pressure.