A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?

Provide information about stress management.

Administer epinephrine for acute episodes.

Maintain a cool temperature in the client's room.

Give a glucocorticoid steroid twice per day.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Provide information about stress management.: Stress is a major trigger for vasospastic episodes in Raynaud’s disease because it increases sympathetic nervous system activity, causing further arterial constriction. Stress-reduction techniques such as deep breathing, biofeedback, or relaxation exercises helps reduce the frequency and severity of attacks.

B. Administer epinephrine for acute episodes.: Epinephrine causes vasoconstriction, which would worsen Raynaud’s symptoms by further reducing blood flow to the extremities. During an acute episode, warming the affected areas and avoiding additional vasoconstrictors is essential. Epinephrine is not indicated as a treatment and can intensify ischemic discomfort

C. Maintain a cool temperature in the client's room.: Cold temperatures are one of the most common triggers for vasospasm in Raynaud’s disease. A cool environment increase the likelihood of an episode by promoting peripheral vasoconstriction. The nurse should provide a warm environment and encourage protective clothing to maintain circulation.

D. Give a glucocorticoid steroid twice per day.: Steroids are not a standard treatment for Raynaud’s because the condition is related to vasospasm rather than inflammatory processes. Routine steroid use would expose the client to unnecessary adverse effects without addressing the underlying problem. Management strategies focus instead on warmth, lifestyle modification, and vasodilator medications when needed.

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Correct Answer is C

Explanation

Rationale:

A. Hyperkalemia: Furosemide is a loop diuretic that promotes potassium excretion, which can lead to hypokalemia, not hyperkalemia. Monitoring for low potassium is important, but hyperkalemia is not a primary concern with these medications.

B. Hypoglycemia: Neither furosemide nor gentamicin directly affects blood glucose levels. Hypoglycemia is not a typical complication of these medications.

C. Ototoxicity: Gentamicin, an aminoglycoside antibiotic, and furosemide, a loop diuretic, can both cause ototoxicity, which may result in tinnitus, hearing loss, or balance disturbances. Monitoring for auditory changes is essential when these medications are used concurrently.

D. Liver toxicity: These medications are not primarily hepatotoxic. Liver function monitoring is not a routine requirement for furosemide or gentamicin unless there are other predisposing conditions.

A. Evaluate why the client was not ambulated. B. Ambulate the client on behalf of the AP. C. Supervise the AP performing the task. D. Remind the AP of her assigned tasks.

Correct Answer is A

Explanation

Rationale:

A. Evaluate why the client was not ambulated.: The first step in addressing a missed delegated task is to assess the reason it was not completed. Understanding whether barriers were related to the AP, client condition, workload, or communication helps the nurse plan corrective action and prevents recurrence.

B. Ambulate the client on behalf of the AP.: While ensuring the client’s needs are met is important, jumping straight to performing the task bypasses assessment of the underlying issue. Immediate action may address the symptom but not the cause of the missed delegation.

C. Supervise the AP performing the task.: Supervision is appropriate for ongoing tasks but is not the first action once a task has already been missed. The nurse must first determine why the task was not completed before implementing supervision.

D. Remind the AP of her assigned tasks.: Reminding the AP without assessing why the task was missed does not address potential systemic or situational barriers. It may be necessary later but is not the initial step in problem resolution.

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A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has prescriptions for furosemide and gentamicin. For which of the following complications should the nurse monitor the client?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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