A nurse is collecting data from a client who is taking aspirin.
Which of the following findings should the nurse report to the provider?
Headache.
Rhinitis.
Hct 43%.
BP 120/70 mm Hg.
The Correct Answer is B
Choice A rationale:
While headache can be a side effect of aspirin, it’s usually not severe enough to warrant reporting to the provider unless it’s persistent or severe.
Choice B rationale:
Rhinitis, or inflammation of the mucous membrane of the nose, can be an allergic reaction to aspirin and should be reported to the provider.
Choice C rationale:
Hematocrit (Hct) level of 43% is within the normal range for both men (38.8–50.0 %) and women (34.9–44.5 %), so this finding would not need to be reported.
Choice D rationale:
A blood pressure reading of 120/70 mm Hg is within the normal range and would not need to be reported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Fever is not a common side effect of acetaminophen. In fact, acetaminophen is often used to reduce fever.
Choice B rationale:
Jaundice, which is a yellowing of the skin or eyes, can be a sign of liver damage, a rare but serious side effect of acetaminophen.
Choice C rationale:
Diarrhea is not a common side effect of acetaminophen.
Choice D rationale:
Tinnitus, or ringing in the ears, is not a common side effect of acetaminophen.
Correct Answer is C
Explanation
Choice A rationale:
Checking blood pressure with the client standing could exacerbate the client’s symptoms due to orthostatic hypotension, which is a common side effect of captopril.
Choice B rationale:
Administering a 0.9% sodium chloride IV bolus could be considered if the client’s blood pressure does not improve with positioning changes or if the client’s condition worsens.
Choice C rationale:
Placing the client in a supine position can help increase blood flow to the brain and alleviate symptoms of low blood pressure. This should be the first action taken by the nurse.
Choice D rationale:
Measuring blood pressure with the client sitting could also exacerbate symptoms due to orthostatic hypotension. It would be more appropriate after the client’s condition has stabilized.
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