Nokea
The nurse initiates an infusion of piperacillin-tazobactam for a client with a urinary tract infection. Five minutes into the infusion, the client reports not feeling well. Which client manifestation should the nurse identify as a reason to stop the infusion?
- A. Hypertension.
- B. Scratchy throat.
- C. Bradycardia.
- D. Pupillary constriction.
Correct Answer: B
Rationale: A scratchy throat (B) may indicate an allergic reaction, potentially anaphylaxis, requiring immediate cessation of the piperacillin-tazobactam infusion and assessment. Hypertension (A), bradycardia (C), and pupillary constriction (D) are not typical signs of an allergic response to this antibiotic.
You may also like to solve these questions
A patient with open-angle glaucoma asks the nurse about the duration of use for the prescribed eye drops. What is the nurse’s accurate response?
- A. For long-term control of pain and swelling.
- B. Until a smaller angle can be restored.
- C. Until the excess pressure is reduced.
- D. For long-term control of normal eye pressure.
Correct Answer: D
Rationale: Open-angle glaucoma requires lifelong eye drops to maintain normal intraocular pressure (D). They don’t control pain/swelling (A) or restore angles (B). Pressure reduction (C) is ongoing, not temporary.
A female patient with multiple sclerosis reports less fatigue and improved memory since she started using the herbal supplement, ginkgo biloba. What is the most important information for the nurse to include in the teaching plan for this patient?
- A. Nausea and diarrhea can occur when using this supplement.
- B. Ginkgo biloba use should be limited and not taken during pregnancy.
- C. Aspirin and non-steroidal anti-inflammatory drugs interact with ginkgo.
- D. Anxiety and headaches increase with the use of ginkgo biloba.
Correct Answer: C
Rationale: This question is identical to Question 39. Ginkgo biloba’s interaction with aspirin/NSAIDs (C) increases bleeding risk, a critical teaching point. Other side effects (A, D) and pregnancy limits (B) are less urgent. Note: Duplicate question; consider removing.
The nurse is preparing to administer a scheduled dose of labetalol orally to a client with hypertension. The client’s vital signs are temperature 99° F (37.2 C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (BP) 150/90 mm Hg. What action should the nurse take?
- A. Withhold the scheduled dose and notify the healthcare provider.
- B. Administer the dose and monitor the client’s BP regularly.
- C. Assess for orthostatic hypotension before administering the dose.
- D. Apply a telemetry monitor before administering the dose.
Correct Answer: A
Rationale: Labetalol, a beta-blocker, can worsen bradycardia (heart rate 48 bpm). Withholding the dose and notifying the provider (A) is safest. Administering (B) risks exacerbating bradycardia. Orthostatic hypotension assessment (C) and telemetry (D) are secondary.
A patient who received a renal transplant three months ago is readmitted to the acute care unit with signs of graft rejection. During the patient’s history taking, the nurse finds out that the patient has been self-administering St. John’s Wort, an herbal preparation, on a friend’s advice. What information is most significant about this finding?
- A. St. John’s Wort can decrease plasma concentrations of cyclosporine.
- B. Consumption of St. John’s Wort can reduce the patient’s sodium intake.
- C. Adding the herb can decrease the need for corticosteroids.
- D. The patient probably used this herb to treat depression.
Correct Answer: A
Rationale: St. John’s Wort induces CYP3A4, reducing cyclosporine levels (A), risking transplant rejection. It doesn’t affect sodium (B) or reduce corticosteroid needs (C). Depression treatment (D) is secondary to the transplant risk.
Which intervention is most important for the nurse to implement for a client who is receiving insulin lispro?
- A. Assess for hypoglycemia between meals.
- B. Check blood glucose levels every six hours.
- C. Provide meals at the same time this insulin is given.
- D. Keep an oral liquid or glucose source available.
Correct Answer: C
Rationale: Insulin lispro, a rapid-acting insulin, peaks quickly and should be given with meals (C) to match food intake and prevent hypoglycemia. Assessing for hypoglycemia (A) and keeping glucose sources (D) are important but secondary. Six-hour glucose checks (B) are too infrequent.