A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and the least priority last or at the bottom.)

Stop the Infusion.

Assess vital signs

Contact the healthcare provider.

Initiate an adverse event report.

Document reaction to the drug.

Answer and Explanation

The Correct Answer is A,B,C,D,E

A)   This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B)   Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C)   The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D)   The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E)   The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.

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Correct Answer is ["A","B","D"]

Explanation

The correct answer isa. Place a bedside commode next to bed.,b. Measure neurological vital signs every 4 hours.,d. Encourage family to participate in the client’s care.

Choice A rationale:

Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.

Choice B rationale:

Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.

Choice C rationale:

Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management.Routine suctioning can also cause discomfort and potential injury.

Choice D rationale:

Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process.Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.

Choice E rationale:

Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation.The effectiveness of music therapy can vary based on individual preferences.

A. Report any difficulty with breathing. B. Monitor for changes in stool color. C. Avoid the consumption of grapefruit juice. D. Take the medication with antacids.

Correct Answer is D

Explanation

Itraconazole is an antifungal medication used to treat a variety of fungal infections. Antacids, which are used to treat heartburn and acid reflux, can decrease the absorption of itraconazole in the body. Therefore, it is important to instruct the client to avoid taking itraconazole with antacids. If the client needs to take an antacid, it should be taken at least 2 hours before or after taking itraconazole.

Reporting any difficulty with breathing is important as it can be a sign of an allergic reaction to the medication. Monitoring for changes in stool color is important as it can be an indication of liver dysfunction, which is a potential side effect of itraconazole.

Avoiding the consumption of grapefruit juice is important as it can increase the level of itraconazole in the body, which can increase the risk of side effects.

In summary, the client should be instructed to avoid taking itraconazole with antacids and to take any antacid at least 2 hours before or after taking itraconazole. The client should also be instructed to report any difficulty with breathing and to monitor for changes in stool color. Additionally, the client should avoid consuming grapefruit juice while taking itraconazole.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A client receives a prescription for itraconazole. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is D

Explanation

A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?

The nurse is providing discharge teaching to a client who underwent a pneumonectomy. The client wants to resume social activities with family. How should the nurse respond?

An adult client is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the client is the earliest indication to the nurse that the client is experiencing an adverse reaction to this procedure?

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

A client who has been taking allopurinol prophylactically comes into the clinic with reoccurring gout attack episodes in left ankle. The healthcare provider changes the prescription to febuxostat. Which instruction should the nurse include in the discharge teaching?

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)