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When a client reports being allergic to penicillin, which question should the nurse ask to gather more information?
- A. Are you allergic to any other medications?
- B. How often have you taken penicillin in the past?
- C. Is anyone else in your family allergic to penicillin?
- D. What happens to you when you take penicillin?
Correct Answer: D
Rationale: Rationale: Option D is the correct answer because it directly addresses the client's experience with penicillin, providing crucial details about the allergic reaction. By asking what happens when the client takes penicillin, the nurse gains specific information to assess the severity and type of allergic reaction. This helps in determining appropriate interventions and alternative medications. Options A, B, and C are incorrect as they do not focus on gathering detailed information about the client's allergic reaction to penicillin. Option A is too broad, option B is not relevant to the current situation, and option C does not directly address the client's individual experience.
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The healthcare provider is caring for a client with a chest tube. Which assessment finding requires immediate intervention?
- A. Intermittent bubbling in the water seal chamber.
- B. Drainage of 75 ml in the first hour post-insertion.
- C. Crepitus around the insertion site.
- D. Fluctuation of the water level in the water seal chamber with respiration.
Correct Answer: C
Rationale: The correct answer is C: Crepitus around the insertion site. Crepitus suggests subcutaneous emphysema, which can indicate a pneumothorax or air leak. Immediate intervention is needed to prevent further complications.
A: Intermittent bubbling in the water seal chamber is expected and indicates a functioning chest tube system.
B: Drainage of 75 ml in the first hour post-insertion is within the normal range and should be monitored.
D: Fluctuation of the water level in the water seal chamber with respiration is a normal finding indicating the chest tube is functioning correctly.
When a client expresses, 'I don't know how I will go on' while discussing feelings related to a recent loss, the nurse remains silent. What is the most likely reason for the nurse's behavior?
- A. The nurse is indicating disapproval of the statement.
- B. The nurse is showing respect for the client's loss.
- C. Silence is mirroring the client's sadness.
- D. Silence enables the client to contemplate what was expressed.
Correct Answer: D
Rationale: The correct answer is D because the nurse's silence allows the client to reflect on and process their emotions after expressing uncertainty about the future. By remaining silent, the nurse gives the client space to explore their feelings and thoughts without interruption. This can help the client gain insight and come to terms with their emotions.
A: The nurse's silence does not indicate disapproval, as it is a common therapeutic technique.
B: While the nurse may be showing respect for the client's loss, the primary reason for the silence is to facilitate the client's reflection.
C: Although silence can sometimes mirror the client's emotions, the main purpose here is to enable contemplation rather than direct mirroring.
A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 a.m. and the nurse is running behind schedule. Which medication should the nurse administer first?
- A. Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours.
- B. Vancomycin (Vancocin) 1 gm in 250 ml D5W, IV over 90 minutes q12 hours.
- C. Pantoprazole (Protonix) 40 mg PO daily.
- D. Enoxaparin (Lovenox) 40 mg subq q24 hours.
Correct Answer: A
Rationale: The correct answer is A: Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours. In a patient with urinary sepsis, timely administration of antibiotics is crucial to prevent further complications. Piperacillin/tazobactam is a broad-spectrum antibiotic effective against a wide range of bacteria commonly involved in sepsis. Administering it first ensures prompt initiation of treatment. Other choices (B) Vancomycin, (C) Pantoprazole, and (D) Enoxaparin are important medications but are not as time-sensitive in this scenario. Vancomycin and Enoxaparin have longer administration times, and Pantoprazole is a maintenance medication that is not urgent in the acute management of sepsis.
The healthcare provider prescribes naproxen (Naprosyn) 500 mg PO twice a day for a client with osteoarthritis. During a follow-up visit one month later, the client tells the nurse, 'The pills don't seem to be working. They are not helping the pain at all.' Which factor should influence the nurse's response?
- A. Noncompliance is probably affecting optimal medication effectiveness.
- B. Drug dosage is inadequate and needs to be increased to three times a day.
- C. The drug needs 4 to 6 weeks to reach therapeutic levels in the bloodstream.
- D. NSAID response is variable, and trying another NSAID may be more effective.
Correct Answer: D
Rationale: Step 1: NSAID response is variable - Different individuals respond differently to NSAIDs like naproxen due to genetic and physiological differences.
Step 2: Trying another NSAID may be more effective - If the current NSAID is not effective, switching to a different one with a different mechanism of action may provide better pain relief.
Step 3: Individualized approach - Tailoring the treatment to the individual's response is key in managing osteoarthritis pain effectively.
Summary: Choice D is correct as it acknowledges the variability in NSAID response and suggests trying another NSAID if the current one is ineffective. Choices A, B, and C are incorrect as they do not address the variable response to NSAIDs and do not provide a solution to address the lack of pain relief.
A client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the healthcare team implement first?
- A. Notify the healthcare provider of the assessment findings.
- B. Determine if the client received anesthesia during delivery.
- C. Assign a licensed nurse to reassess the client's vital signs.
- D. Obtain a STAT hemoglobin and hematocrit.
Correct Answer: B
Rationale: The correct answer is B because the client delivered a 7-pound infant 12 hours ago and is now experiencing a severe headache, which could indicate postpartum preeclampsia. Checking if the client received anesthesia during delivery is crucial as certain types of anesthesia can increase the risk of postpartum preeclampsia. This step is important to determine if anesthesia is a contributing factor to the client's symptoms.
Option A is incorrect because immediate action is needed to address the client's symptoms related to anesthesia. Option C is incorrect as reassessing vital signs alone may not provide information specific to the client's headache. Option D is incorrect as obtaining a hemoglobin and hematocrit would not directly address the client's headache or potential anesthesia-related issues.