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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. The client had a decreased neutrophil count before the medication was administered: This finding may be expected in a client undergoing cytotoxic chemotherapy and receiving filgrastim to stimulate neutrophil production. It is not an indication for an incident report.
B. The client had chemotherapy 12 hr before the medication was administered: The timing of chemotherapy administration is not typically a reason to complete an incident report unless it conflicts with specific medication guidelines or protocols.
C. The vial was out of the refrigerator for 2 hr before the medication was administered:

Filgrastim should be stored in the refrigerator and protected from light. Allowing the medication vial to be out of the refrigerator for an extended period may compromise its stability and effectiveness, potentially leading to adverse effects or reduced efficacy. Therefore, this finding warrants completion of an incident report.
D. The client reported feeling nauseous after the medication was administered: Nausea is a known side effect of filgrastim and is not typically an indication for completing an incident report unless it is severe or persistent and requires intervention.

A. "Do not chew more than 40 pieces of gum per day." B. "Allow 9 months for the gum to achieve the therapeutic effect." C. "Chew the gum slowly over 30 minutes." D. "Drink a glass of water 5 minutes before chewing the gum."

Correct Answer is C

Explanation

A. This statement is incorrect. While it’s essential not to exceed the recommended dose, the

maximum daily limit for nicotine gum is 24 pieces, not 40. Using more than the recommended amount can lead to adverse effects
B. This information is not accurate. Nicotine gum is typically used for a shorter duration. The

treatment plan varies, but it’s essential to follow the recommended dosing and gradually reduce usage over time. The goal is to quit smoking successfully, not to use the gum for 9 months
C. This advice is correct. Nicotine gum is not used like ordinary chewing gum. You should chew it a few times and then “park” it between your cheek and the space below your teeth. The nicotine is absorbed mostly in your mouth. Chewing it slowly over 30 minutes allows for
effective absorption and helps control withdrawal symptoms

D. Drinking water before chewing nicotine gum is not a necessary instruction for its use.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who just received a dose of IV filgrastim. The client has cancer and is receiving cytotoxic chemotherapy. For which of the following findings should the nurse complete an incident report?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who reports smoking 3 packs of cigarettes per day and has a prescription for nicotine gum. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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