A nurse in a provider's office is caring for a client.
Nurses' Notes
3 months ago:
Client seen in provider's office for routine physical. Today:
Client reports dizziness and light-headedness upon standing. Client reports waking up at night to void.
What actions should the nurse take? Select all that apply.
Advise the client to change positions slowly.
Check the client for orthostatic hypotension. Monitor the client for dysrhythmias.
Advise the client to restrict potassium intake.
Advise the client to take the medication before bedtime.
Correct Answer : A,B
A. Advise the client to change positions slowly: The client's symptoms of dizziness and light- headedness upon standing suggest orthostatic hypotension, which can be managed by advising the client to change positions slowly to minimize blood pressure drops upon standing.
B. Check the client for orthostatic hypotension. Monitor the client for dysrhythmias: The client's symptoms, along with the report of waking up at night to void, are suggestive of orthostatic hypotension, a drop in blood pressure upon standing. Checking for orthostatic hypotension and monitoring for dysrhythmias are appropriate nursing actions to assess and manage this condition.
C. Advise the client to restrict potassium intake: Restricting potassium intake is not indicated based on the client's symptoms of dizziness and light-headedness. This action is not relevant to the situation described.
D. Advise the client to take the medication before bedtime: There is no indication in the scenario provided that medication timing is related to the client's symptoms. This action is not relevant to addressing the client's reported symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bruxism: Bruxism, or teeth grinding, is a potential adverse effect of citalopram but is generally less severe than confusion. While it should be monitored and reported if severe or persistent, it is not typically considered a priority adverse effect.
B. Confusion: Confusion can indicate a serious adverse reaction or complication, such as serotonin syndrome, which is a potentially life-threatening condition associated with the use of selective serotonin reuptake inhibitors (SSRIs) like citalopram. Therefore, confusion is the priority adverse effect to report to the provider.
C. Insomnia: Insomnia is a common side effect of citalopram and other SSRIs but is generally less severe than confusion. It should be monitored and reported if severe or persistent, but it is not typically considered a priority adverse effect.
D. Weight loss: Weight loss can occur as a side effect of citalopram but is generally less severe than confusion. It should be monitored and reported if excessive or rapid, but it is not typically considered a priority adverse effect.
Correct Answer is ["1.5"]
Explanation
Convert the client's weight from pounds to kilograms by dividing by 2.2. 198 lb / 2.2 = 90 kg
Calculate the dose of filgrastim in micrograms by multiplying the client's weight in kilograms by the prescribed dose per kilogram. 90 kg x 5 mcg/kg = 450 mcg
Calculate the volume of filgrastim in milliliters by dividing the dose in micrograms by the concentration of the available solution. 450 mcg / 300 mcg/mL = 1.5 mL
Round the answer to the nearest tenth. The nurse should plan to give 1.5 mL of filgrastim with each dose.
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