A nurse is preparing to administer lidocaine 50 mg IV bolus.
Available is lidocaine 200 mg/mL. How many mL should the nurse administer per dose? rounded off to the nearest hundredth

The correct answer is to select the following three findings that require immediate follow-up:C. Urticaria,D. Blood pressure at 1630, andE. Report of dysphagia.

Choice A rationale:

“Breath sounds at 1600.” The breath sounds at 1600 were clear and present throughout, which is a normal finding and does not require immediate follow-up.

Choice B rationale:

“Temperature.” The temperature readings at both 1600 and 1630 are slightly elevated but not critically high. This does not require immediate follow-up compared to the other findings.

Choice C rationale:

“Urticaria.” The presence of urticaria (hives) indicates an allergic reaction, which can potentially escalate to a more severe reaction such as anaphylaxis.Immediate follow-up is necessary to prevent further complications.

Choice D rationale:

“Blood pressure at 1630.” The blood pressure at 1630 is significantly lower (78/52 mm Hg) compared to the earlier reading (110/58 mm Hg).This hypotension could indicate a serious reaction to the medication or another underlying issue that requires prompt attention.

Choice E rationale:

“Report of dysphagia.” The client’s report of difficulty swallowing and feeling a lump in their throat is concerning for a potential airway obstruction or severe allergic reaction, such as anaphylaxis.This symptom requires immediate follow-up to ensure the client’s airway remains open and to provide necessary interventions.