A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

Hypotension

Muscle pain

Ototoxicity

Hyperthermia

Answer and Explanation

The Correct Answer is A

A.   Verapamil, as a calcium channel blocker, can cause vasodilation (widening of blood vessels), which can lead to a decrease in blood pressure. Monitoring for hypotension is crucial when administering verapamil, especially via IV bolus, as it can rapidly lower blood pressure and potentially lead to symptoms such as dizziness, lightheadedness, or fainting.
B.   Muscle pain is not a common or expected adverse effect of verapamil. While some medications might cause muscle-related symptoms, verapamil is more commonly associated with cardiovascular effects, such as hypotension and bradycardia, rather than muscle pain.
C.   Ototoxicity is not a known adverse effect of verapamil. Ototoxicity is more commonly associated with other classes of drugs, such as certain antibiotics (e.g., aminoglycosides) or diuretics. Verapamil primarily affects the cardiovascular system, so ototoxicity is not a concern with this medication.
D.   Hyperthermia is not a common adverse effect of verapamil. Verapamil does not typically affect body temperature regulation. Conditions associated with hyperthermia are more likely related to infections, overheating, or certain other medications, but not verapamil.

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

Explanation

A. Obtain a wound culture: While important, it is not the immediate priority compared to fluid resuscitation, antibiotic administration, and lactate level measurement.
B. Early administration of antibiotics is crucial in sepsis management to prevent further tissue damage and organ dysfunction.
C. Fluid resuscitation is essential to improve blood pressure and organ perfusion. Rapid administration of fluids is necessary to stabilize the patient.
D. Inserting a nasogastric (NG) tube might be necessary later if the patient develops gastrointestinal issues, but it's not an immediate priority.

E. While blood transfusion might be necessary if the patient becomes severely hypotensive, it's not the initial step. Fluid resuscitation is attempted first.
F. Urine culture can be helpful in identifying the source of infection but is not the immediate priority.
G. Lactate levels are a biomarker for tissue hypoxia and can help assess the severity of sepsis.
H. Blood cultures are essential to identify the causative organism for targeted antibiotic therapy.

A. "I will look up at the ceiling when I swallow." B. "I will have to stop watching television while I eat." C. "My food will have to be the consistency of pudding." D. "I can have cream soups on this diet." E. "I shouldn't drink liquids while I have food in my mouth." F. "I won't be able to eat nuts anymore."

Correct Answer is ["B","C","E","F"]

Explanation

A. "I will look up at the ceiling when I swallow.". The recommended position for swallowing is typically sitting upright with the chin slightly tucked.
B. "I will have to stop watching television while I eat." This indicates an understanding of the importance of focusing on eating and avoiding distractions.
C. "My food will have to be the consistency of pudding." This indicates understanding of the Level 3 dysphagia diet, which requires foods to be moist and easily swallowed.
D. "I can have cream soups on this diet." While cream soups might seem like a good option, they can be too thick for a Level 3 dysphagia diet. The consistency should be more like a thin purée.
E. "I shouldn't drink liquids while I have food in my mouth." This demonstrates understanding of the importance of avoiding choking hazards.
F. "I won't be able to eat nuts anymore." This indicates understanding of the restrictions on hard, crunchy foods on a Level 3 dysphagia diet.

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A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

Nursing Test Bank

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Explanation

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