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A nurse is caring for afemale client in an outpatient clinic.

Exhibits
Click to highlight the findings that require immediate follow-up. Tо deselect a finding, click on the finding again.

Nurses' Notes

Day 1:

Client is seen by provider for routine follow-up after being started on oxcarbazepine 150mg PO twice a day, last week. Client reports no nausea, headache, dizziness, or ataxia. Provider increased oxcarbazepine to 300 mg PO twice a day. Client is to return for a follow-up in 2 weeks.

Day 14:

Client returns for follow-up after increasing oxcarbazepine dosage. Client reports starting to have mild headaches earlier this week. Also states, "Yesterday I was very nauseated and threw up before breakfast." When talking to client they have difficulty remembering the times they are taking their oxcarbazepine. Client reports using oral contraceptives as the only means of birth control.

Laboratory Results

Day 14:

Hct 40% (37% to 47%)

Hgb 13g/dL (12 to 16g/dL)

Sodium 124 mEq/L (136 to 145 mEq/L)

Vitals Signs

Day 14:

Temperature 36.3° C (97.4° F)

Heart rate 86/min

Blood pressure 110/66 mm Hg

Respiratory rate 16/min

Client reports starting to have mild headaches earlier this week.

Also states, "Yesterday I was very nauseated and threw up before breakfast."

When talking to client they have difficulty remembering the times they are taking their oxcarbazepine.

Client reports using oral contraceptives as the only means of birth control.

Hct 40% (37% to 47%)

Hgb 13g/dL (12 to 16g/dL)

Sodium 124 mEq/L (136 to 145 mEq/L)

Temperature 36.3° C (97.4° F)

Heart rate 86/min

Blood pressure 110/66 mm Hg

Answer and Explanation

The Correct Answer is ["B","C","G"]

Rationale for correct choices:

Sodium 124 mEq/L: The client’s serum sodium is critically low, indicating severe hyponatremia, a known serious adverse effect of oxcarbazepine. Hyponatremia can lead to confusion, seizures, and potentially life-threatening neurological complications, requiring immediate provider follow-up and possible medication adjustment or discontinuation.
Difficulty remembering medication times: Cognitive changes or confusion may indicate central nervous system effects of oxcarbazepine or complications from hyponatremia. This finding signals the need for urgent reassessment and intervention to prevent medication errors or toxicity.
Nausea/vomiting: Persistent nausea and vomiting, especially after a recent dose increase, may be a sign of drug intolerance, early hyponatremia symptoms, or central nervous system effects. Immediate follow-up is necessary to prevent further complications and dehydration.

Rationale for Incorrect Choices:

Mild headache: While headaches may occur with oxcarbazepine, the mild nature and recent onset are less urgent compared with severe hyponatremia and neurological symptoms.
Vital signs (HR 86, BP 110/66, Temp 36.3° C, RR 16): These are slightly lower than baseline but not immediately concerning. The priority is lab abnormality and neurological changes.
Hct 40%, Hgb 13 g/dL: These values remain within normal limits and do not require immediate intervention.
Use of oral contraceptives: This is important for counseling because oxcarbazepine can reduce contraceptive efficacy, but it is not an urgent clinical finding compared to hyponatremia.

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Correct Answer is C

Explanation

A. "I have vomited several times.": Vomiting can be a side effect of penicillin, but it is usually manageable and not immediately life-threatening unless severe dehydration occurs.

B. "I am having diarrhea.": Mild diarrhea is a common side effect of antibiotics. It is important to monitor for signs of C. difficile infection, but occasional loose stools are not immediately critical.

C. "I am having trouble swallowing.": Difficulty swallowing may indicate oropharyngeal edema, which can be a sign of a severe allergic reaction to penicillin. This requires immediate attention as it can progress to airway obstruction.

D. "My skin feels itchy all over.": Generalized itching may indicate a mild allergic reaction. While it should be monitored, it is less urgent than symptoms suggesting airway compromise.

A. Temperature B. Blood pressure C. Pain level D. Respiratory rate

Correct Answer is D

Explanation

A. Temperature: Propofol does not typically affect body temperature in the short term during outpatient procedures, so monitoring temperature is not the immediate priority.

B. Blood pressure: Propofol can cause hypotension, so blood pressure monitoring is important, but it is secondary to assessing airway and breathing because respiratory depression can be life-threatening.

C. Pain level: Propofol provides sedation and amnesia but not analgesia. Pain assessment is relevant post-procedure, but during administration, airway and breathing take precedence.

D. Respiratory rate: Propofol can cause significant respiratory depression, including apnea. Continuous monitoring of respiratory rate and oxygenation is the priority to detect and respond to life-threatening airway compromise immediately.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an infection and has been taking penicillin. Which of the following statements by the client should the nurse identify as the priority to report to the provider?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving propofol for an outpatient colonoscopy. Which of the following is a priority for the nurse to monitor?

Correct Answer is D

Explanation

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