Exhibits
For each body system, click tanto specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention. Each category must have at least one response option selected.
|
Body system |
Potential nursing intervention |
|
Cardiovascular |
Monitor vital signs continuously Provide warmth Echocardiogram Defibrillator at bedside |
|
Immunological |
Administer steroid Assess rash IV fluids Administer antihistamine |
|
Respiratory |
Assess lung sounds Pain medication Provide calm environment Chest x-ray |
Monitor vital signs continuously
Echocardiogram
Assess rash
Administer antihistamine
Assess lung sounds
Provide calm environment
Provide warmth
Defibrillator at bedside
Administer steroid
IV fluids
Pain medication
Chest x-ray
The Correct Answer is ["A","B","C","D","E","F"]
Monitor vital signs continuously: This is crucial to detect any further changes in heart rate or blood pressure, especially given the client’s history of symptomatic bradycardia and recent hypotensive episode following vancomycin administration.
Echocardiogram: This is appropriate post-pacemaker insertion to assess cardiac function and ensure the pacemaker is functioning properly.
Immunological:
Administer antihistamine: Given the client’s adverse reaction to vancomycin, which included hives, flushing, and itching, administering an antihistamine like diphenhydramine is appropriate.
Assess rash: Monitoring the progression or improvement of the rash will help evaluate the effectiveness of the interventions and the resolution of the allergic reaction.
Respiratory:
Assess lung sounds: It's important to evaluate the client’s respiratory status, especially given the shortness of breath reported post-operatively, which could indicate a reaction to the medication or a complication from the procedure.
Provide calm environment: This intervention helps in reducing anxiety and stress, which can exacerbate symptoms and impact cardiovascular and respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. There is no specific need to avoid dairy products when taking bulk-forming laxatives.
B. It is not necessary to remain upright for thirty minutes after taking a bulk-forming laxative.
C. Bulk-forming laxatives should be taken with or shortly after meals and not necessarily one hour later to avoid interactions.
D. Bulk-forming laxatives need to be taken with plenty of water to prevent choking and ensure they work effectively.
Correct Answer is D
Explanation
A. While breastfeeding is not recommended during isotretinoin therapy, the most pressing concern for pregnancy is to discontinue the medication before conception.
B. Isotretinoin can be harmful if excessive vitamin A is taken, but the critical issue is to stop the medication before pregnancy.
C. Monitoring liver function is important during isotretinoin therapy but does not directly address the pregnancy-related risk.
D. Isotretinoin is highly teratogenic, so it is crucial to discontinue the medication at least one month before attempting to conceive to avoid potential birth defects.
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