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A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

A.

A client who was administered acyclovir for cellulitis reports pain in the affected leg

B.

A client who was administered adalimumab for Crohn’s disease, has a serum calcium level of 10 mg/dL, and reports a headache

C.

A client who was administered erythromycin for acute glomerulonephritis and reports reddish brown urinary output

D.

A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dl

Answer and Explanation

The Correct Answer is D

A. Pain in the affected leg could indicate worsening of cellulitis or a potential complication like deep vein thrombosis (DVT), but there is no immediate indication of a life-threatening condition. This client should be assessed, but may not be the top priority unless other signs of complications are present.

B. A serum calcium level of 10 mg/dL is within the normal range (8.5 to 10.5 mg/dL). A headache, while concerning, is not immediately life-threatening unless there are additional symptoms suggesting something more severe.

C.Reddish brown urine suggests hematuria, a symptom of glomerulonephritis. This could indicate ongoing kidney issues, but unless there are signs of severe kidney failure or systemic infection, this might not be the most urgent case.

D. A blood glucose level of 68 mg/dL is low and can lead to hypoglycemia, which can be immediately life-threatening if it progresses to severe hypoglycemia. Symptoms of hypoglycemia include confusion, dizziness, sweating, and can escalate to seizures or unconsciousness if not promptly treated.


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Related Questions

Correct Answer is A

Explanation

A. Suppress respiratory effort
Pancuronium is a neuromuscular blocking agent that is often used to induce paralysis in patients requiring mechanical ventilation. It works by blocking the transmission of nerve impulses at the neuromuscular junction, leading to skeletal muscle paralysis. In the context of a client with acute respiratory distress syndrome (ARDS) on mechanical ventilation, the use of pancuronium helps to suppress respiratory effort, allowing for better control of the patient's ventilation and oxygenation.

B. Decrease chest wall compliance:
Pancuronium does not directly affect chest wall compliance. It primarily acts on skeletal muscles, leading to paralysis.

C. Decrease respiratory secretions:
Pancuronium is not used to decrease respiratory secretions. It is a neuromuscular blocking agent with the main goal of inducing paralysis.

D. Induce sedation:
Pancuronium does not induce sedation. It works on the neuromuscular junction and does not have sedative properties. Sedation may be achieved with other medications, such as sedative agents.

Correct Answer is C

Explanation

A. Glucagon:
Glucagon is not used as an antidote for heparin overdose. It is typically used to treat severe hypoglycemia.

B. Vitamin K:
Vitamin K is the antidote for warfarin, another anticoagulant, but it is not effective for reversing the effects of heparin.

C. Protamine
Protamine is the specific antidote for heparin. It acts by binding to heparin, neutralizing its anticoagulant effects. It is important to note that the administration of protamine should be done carefully, and the dosage must be based on the amount of heparin the patient has received.

D. Calcium:
Calcium is not an antidote for heparin. It is more relevant in cases of calcium channel blocker toxicity or hypocalcemia.

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