A nurse is assisting with the care of a client.
Vital Signs.
1330: Temperature 36.8 °C (98.2 °F) Heart rate 88/min.
Respiratory rate 16/min.
Blood pressure 110/64 mm Hg. 1345: Oxygen saturation 96% on 3 L/min via simple face mask.
Temperature 37 °C (98.6 °F) Heart rate 112/min.
Respiratory rate 20/min.
Blood pressure 108/60 mm Hg. 1400: Oxygen saturation 94% on 3 L/min via simple face mask.
Temperature 38.3 °C (101 °F) Heart rate 152/min.
For each data collection finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.
Each finding may support more than 1 disease process.
Wheezes
Muscle rigidity
Urticaria
Hypercapnia
Tachycardia
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A,B,C"}}
Wheezes: This finding may indicate a latex allergy, as wheezing is a sign of respiratory distress caused by an allergic reaction to latex proteins. Wheezes are not typical of malignant hyperthermia or hypovolemic shock.
Muscle rigidity: This finding is a hallmark of malignant hyperthermia, as it reflects the excessive calcium release and muscle contraction triggered by certain anesthetic agents. Muscle rigidity is not a feature of latex allergy or hypovolemic shock.
Urticaria: This finding is a common manifestation of latex allergy, as urticaria (hives) is a type of skin rash caused by an allergic reaction to latex proteins. Urticaria is not associated with malignant hyperthermia or hypovolemic shock.
Hypercapnia: This finding is indicative of malignant hyperthermia, as hypercapnia (high carbon dioxide levels in the blood) is a result of increased metabolism and oxygen consumption due to muscle rigidity and fever. Hypercapnia is not usually seen in latex allergy or hypovolemic shock, unless there is severe respiratory compromise.
Tachycardia: This finding can be present in all three disease processes, as tachycardia (fast heart rate) is a nonspecific response to stress, fever, pain, hypoxia, or hypovolemia. However, tachycardia is more pronounced and persistent in malignant hyperthermia and hypovolemic shock than in latex allergy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Writing a client's diagnosis on the message board in the client's room can expose sensitive information to anyone who enters the room, which compromises client confidentiality.
Choice B rationale: Discarding worksheets containing client information in a wastebasket is not secure and can lead to unauthorized access to confidential information.
Choice C rationale: Giving change-of-shift report to a nurse outside the client's room protects client confidentiality by ensuring that sensitive information is shared only with authorized personnel in a private setting.
Choice D rationale: While sharing relevant information with personnel directly involved in the client's care is generally acceptable, it must still be done in a manner that safeguards confidentiality.
Correct Answer is C
Explanation
- A. "I can take antacids at the same time as this medication.” This is generally incorrect. While antacids can provide quick relief, they can interfere with the absorption of pantoprazole. It's usually recommended to separate antacid use from pantoprazole by at least a couple of hours.
- B. "I will need to remain upright for 1 hour after taking the medication.” This is incorrect. This is a common instruction for general GERD management, but not specifically related to taking the pantoprazole medication itself.
- C. "I have to take this medication on an empty stomach.” This is generally correct. PPIs like pantoprazole work best when taken before meals, typically 30-60 minutes before breakfast. This allows the medication to be absorbed and ready to reduce acid production when you eat.
- D. "I should expect to have diarrhea while taking this medication.” While diarrhea can be a side effect of pantoprazole, it's not a guaranteed or expected outcome.
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