Nokea
The nurse is assessing the client to update the plan of care.Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. "The nurse determines that the client's is experiencing -----------, and the blood pressure changes are the result of-------------------.
- A. Adverse drug reaction
- B. Antibiotic
- C. Syncope
- D. Heart failure
- E. IV infiltration
Correct Answer: A,B
Rationale: The client’s symptoms (dizziness, hives, etc.) indicate an adverse reaction (Red Man Syndrome) to vancomycin, causing hypotension. Both blanks are correctly filled by 'Adverse drug reaction' and 'Antibiotic' (vancomycin).
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A client with a history of smoking cigarettes for many years arrives at the clinic and expresses a desire to stop smoking. The client receives a prescription for bupropion to reduce nicotine cravings. Which information should the nurse include in the discharge teaching?
- A. Administer each dose with at least 8 ounces of water.
- B. Consume tyramine-free foods while taking the medicine.
- C. Be aware that difficulty sleeping and weight loss may occur.
- D. Notify the healthcare provider if experiencing changes in taste.
Correct Answer: C
Rationale: Bupropion may cause insomnia and weight loss, which are important side effects for the client to understand. Water intake, tyramine-free diets, and taste changes are not primary concerns with bupropion.
The nurse prepares to administer a scheduled dose of labetalol PO to a client with hypertension. The client's vital signs are a temperature of 99° F (37.2° C), a heart rate of 48 beats/minute, respirations of 16 breaths/minute, and a blood pressure of 150/90 mm Hg. Which action should the nurse take?
- A. Apply a telemetry monitor before administering the dose.
- B. Assess for orthostatic hypotension before administering the dose.
- C. Administer the dose and monitor the client's blood pressure regularly.
- D. Withhold the scheduled dose and notify the healthcare provider.
Correct Answer: D
Rationale: A heart rate of 48 beats/minute indicates bradycardia, a concern with labetalol (a beta-blocker). Withholding the dose and notifying the provider is appropriate to prevent worsening bradycardia.
A client is receiving miotics for the treatment of open-angle glaucoma. The nurse determines that a priority nursing problem is 'risk for injury.' This nursing problem is based on which etiology?
- A. Increased frequency of lacrimation.
- B. Decreased night vision.
- C. Increased sensitivity to light.
- D. Diminished color perception.
Correct Answer: B
Rationale: Miotics constrict the pupil, reducing night vision and increasing injury risk in low-light conditions. Lacrimation, photophobia, and color perception changes are less directly linked to injury risk.
A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?
- A. Stores the medication at room temperature.
- B. Primes the inhaler with 7 pumps.
- C. Attaches spacer device to the inhaler.
- D. Rinses the mouth after each use.
Correct Answer: B
Rationale: Priming an ipratropium inhaler with 7 pumps is excessive; typically, 2–3 pumps are needed if unused for a period. Room temperature storage, spacer use, and mouth rinsing are correct practices.
According to the information gathered in the nurse's assessment, the nurse should prepare to give the client [Dropdown 1] and [Dropdown 2].
- A. Insulin glargine
- B. A snack
- C. Glucagon
- D. Ceftriaxone
- E. Juice
- F. A glass of Water
Correct Answer: A,B
Rationale: A blood glucose of 279 mg/dL requires insulin glargine for correction, and a snack prevents hypoglycemia post-insulin.