A nurse is assisting in the care of a female client.
Complete the following sentence by using the lists of options.
The nurse should first address the client'
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale:
The client’s blood pressure of 80/46 mm Hg indicates hypotension, likely due to dehydration from persistent diarrhea. This is the most critical finding, as it can lead to organ hypoperfusion and shock if not addressed immediately. After stabilizing the client’s blood pressure, the nurse should address the client’s low potassium level (3.1 mEq/L), as hypokalemia can cause serious complications, including cardiac arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An adolescent who received a new tattoo last week: A tattoo does not contraindicate live vaccines.
B. A client is at 27 weeks of gestation: Live attenuated vaccines are contraindicated in pregnancy due to potential risk to the fetus.
C. A client who is about to travel to a different country: Travel does not contraindicate the vaccine unless the client has other risk factors.
D. A school-age child who has rhinitis: Mild illness such as rhinitis does not contraindicate live vaccines.
Correct Answer is ["D","G","H"]
Explanation
Client reports having three to four alcoholic beverages a couple times per week: Alcohol can interact with phenytoin, either enhancing its effects or reducing its efficacy. Chronic alcohol use can induce liver enzymes, altering phenytoin metabolism and potentially leading to subtherapeutic or toxic levels.
Client takes diazepam as needed for anxiety: Diazepam and phenytoin can interact, increasing the sedative effects and potentially leading to central nervous system depression. Monitoring is essential when these drugs are coadministered.
Last menstrual period was 3 months ago: This finding may indicate a possible pregnancy, which is critical because phenytoin is teratogenic and classified as a Pregnancy Category D drug. Immediate follow-up is required to rule out pregnancy before starting phenytoin therapy.
Temperature 35.4°C (97.6°F), oral: This is slightly lower than the normal range and does not require immediate follow-up.
Blood pressure 100/74 mmHg: This is within the expected range and does not contraindicate phenytoin use.
Client is a vegetarian and takes a multivitamin daily: A vegetarian diet is not a contraindication, though it may necessitate monitoring for folic acid levels since phenytoin can deplete folate.
Client has varicose veins: Varicose veins do not affect phenytoin use or metabolism.
Last bowel movement was 3 days ago: While mild constipation should be noted, it does not contraindicate phenytoin use.
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