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A nurse in the emergency department is assisting in the care of a client.

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Nurses Notes

1630:

Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields, Diffuse, raised rash present on trunk. Abdomen soft, nontender

Vital Signs

1630:

Temperature 38.3°C (101°F)

Heart rate 110/min

Respiratory rate 30/min

Blood pressure 90/55 mmHg

Oxygen saturation 91% on room air

Client is short of breath

intercostal retractions visible

Wheezing auscultated throughout lung fields

Diffuse, raised rash present on trunk

Respiratory rate 30/min

Blood pressure 90/55 mmHg

Oxygen saturation 91% on room air

Temperature 38.3°C (101°F)

Client is alert and oriented to person, place, and time.

Heart rate 110/min

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

Shortness of breath. The client is experiencing respiratory distress, which could indicate a severe allergic reaction (anaphylaxis). Immediate intervention is needed to prevent airway compromise and respiratory failure.
Intercostal retractions. Retractions occur when breathing is labored, suggesting airway obstruction or bronchoconstriction. This is a sign of worsening respiratory distress, requiring urgent medical attention.
Wheezing auscultated throughout lung fields. Wheezing suggests bronchospasm, which is common in anaphylaxis and asthma attacks. The presence of diffuse wheezing indicates that the airways are narrowing, making breathing more difficult.
Diffuse, raised rash present on trunk. A new-onset rash following antibiotic administration raises suspicion for anaphylaxis or a severe allergic reaction. Immediate treatment with antihistamines and corticosteroids may be required.
Respiratory rate 30/min. The increased respiratory rate indicates that the client is compensating for airway constriction and hypoxia. This is an early warning sign of impending respiratory failure if not treated promptly.
Blood pressure 90/55 mmHg. The drop in blood pressure suggests anaphylactic shock, where vasodilation and fluid leakage from capillaries lead to hypotension. Immediate administration of epinephrine is necessary to prevent cardiovascular collapse.
Oxygen saturation 91% on room air. A decrease in oxygen saturation indicates impaired gas exchange, likely due to airway swelling and bronchospasm. Supplemental oxygen therapy should be provided to prevent further desaturation.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Drowsiness. Dimenhydrinate is an antihistamine that works by blocking histamine and acetylcholine receptors in the brain to prevent nausea and vomiting. A common adverse effect is drowsiness due to its sedative properties, which can impair alertness and coordination. Clients should be advised to avoid activities requiring mental alertness, such as driving, until they understand how the medication affects them.

B. Hypertension. Dimenhydrinate does not typically cause hypertension. Instead, it may lead to mild hypotension due to its sedative and anticholinergic effects. Clients with pre-existing hypertension should still monitor their blood pressure, but significant increases are uncommon.

C. Polyuria. Increased urination is not associated with dimenhydrinate use. Antihistamines, including dimenhydrinate, have anticholinergic properties, which can lead to urinary retention rather than increased urine output. Clients experiencing difficulty urinating should report this to their healthcare provider.

D. Dependent edema. Dimenhydrinate does not cause fluid retention or edema. Medications that contribute to edema typically involve hormonal, cardiovascular, or kidney-related effects, which are not mechanisms of dimenhydrinate. If a client develops unexplained edema, other underlying conditions should be investigated.

A. Levothyroxine B. Cetirizine C. Lithium carbonate D. Albuterol

Correct Answer is C

Explanation

A. Levothyroxine. Levothyroxine is used to treat hypothyroidism and does not have a significant interaction with furosemide. However, both medications require careful monitoring, as hypothyroidism can affect fluid balance, but they are not contraindicated together.

B. Cetirizine. Cetirizine is an antihistamine used to treat allergies and does not interfere with furosemide’s effects. While some antihistamines can cause mild fluid retention, this does not significantly impact furosemide therapy, making them safe to use together.

C. Lithium carbonate. Furosemide is a loop diuretic that increases sodium excretion. Since lithium is excreted through the kidneys in a sodium-dependent manner, a loss of sodium due to diuretic use can lead to reduced lithium excretion and toxic accumulation. Clients taking lithium should avoid diuretics unless absolutely necessary, and their lithium levels must be carefully monitored if diuretics are required.

D. Albuterol. Albuterol is a bronchodilator used for conditions like asthma and COPD. While both furosemide and albuterol can cause hypokalemia, this does not make them absolutely contraindicated. Instead, potassium levels should be regularly monitored, and supplementation may be needed if hypokalemia develops.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is taking dimenhydrinate to treat motion sickness. Which of the following findings is an adverse effect of this medication?

Correct Answer is A

Explanation

A nurse is reviewing a list of current medications for a client who is starting therapy with furosemide. Which of the following medications should the nurse identify as being contraindicated?

Correct Answer is C

Explanation

A nurse is caring for a client who has chronic renal failure and is receiving epoetin alfa. To check for therapeutic effects, the nurse should monitor which of the following client laboratory tests?

A nurse is collecting data from a client who has a new prescription for nitrofurantoin to treat a urinary tract infection. The nurse should monitor the client for which of the following adverse effects?

A nurse is caring for a client who has Graves' disease and is to start therapy with propylthiouracil. The nurse should expect which of the following outcomes?

A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device. Which of the following actions by the nurse requires intervention by the charge nurse?

A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim- sulfamethoxazole. Which of the following statements by the client should indicate to the nurse that the medication is effective?

A nurse is monitoring a client's response to receiving glipizide instead of guaifenesin. Which of the following actions should the nurse take?

A nurse is collecting data from a client following the administration of a new medication. Which of the following findings should the nurse identify as a manifestation of an allergic reaction?

A nurse is caring for a client who is experiencing acute alcohol withdrawal. The nurse should anticipate administering which of the following medications to the client to facilitate the withdrawal process?