Exhibits

The nurse is assessing the client to update the plan of care.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

The nurse determines that the client's is experiencing
dropdown
, and the blood pressure changes are the result of
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Blank 1: Adverse drug reaction: The client’s symptoms of dizziness, headache, burning sensation, redness, flushing, hives, and itching after the administration of vancomycin indicate a severe allergic reaction, likely "Red Man Syndrome," which is an adverse drug reaction.

Blank 2: Antibiotic: The blood pressure changes (initial drop to 108/46 mmHg) are most likely due to the adverse reaction to the vancomycin infusion. The hypotension occurred as a direct result of the antibiotic administration.

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Correct Answer is B

Explanation

A. Administering cephalexin without assessing for potential cross-reactivity to penicillin could put the client at risk of an allergic reaction.
B. Cephalexin, a cephalosporin, may cause allergic reactions, especially in those with a penicillin allergy. Therefore, monitoring for symptoms such as rash or hives is crucial.
C. While it is important to monitor for adverse reactions, contacting the healthcare provider might be unnecessary unless the client shows symptoms of an allergic reaction.
D. Antihistamines are not routinely administered with cephalexin unless prescribed specifically for managing allergic reactions.

A. Demonstrate how to select dose based on before meal blood sugar readings. B. Provide information on increasing medication dosage if ketoacidosis occurs. C. Teach the client self-injection skills for daily subcutaneous administration. D. Explain to the family how to inject this medication for severe hypoglycemia.

Correct Answer is C

Explanation

A. Insulin glargine is a long-acting insulin and is not adjusted based on before meal blood sugar readings; it's typically administered once daily at the same time each day.
B. Adjusting medication dosage for ketoacidosis is not appropriate; insulin glargine is used for baseline blood glucose control, and ketoacidosis requires specific management.
C. Insulin glargine is administered subcutaneously and requires teaching on proper self-injection techniques.
D. Insulin glargine is used for long-term glucose control, not for managing acute severe hypoglycemia, so teaching family injection for hypoglycemia is not relevant here.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of anaphylactic reaction to penicillin receives a prescription for cephalexin 500 mg PO twice daily. Which action should the nurse take?

Correct Answer is B

Explanation

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to include in the discharge teaching?

Correct Answer is C

Explanation

When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. Which action should the nurse take?

A female client who is starting a new prescription for doxycycline hydate tells the nurse that she takes birth control pills. Which action should the nurse take?

A client with a cold is taking the antitussive medication benzonatate. Which assessment information indicates to the nurse that the medication is effective?

A client with chronic asthma receives a prescription for montelukast, a leukotriene modifier. Which statement by the client indicates to the nurse that medication teaching was effective?

A client with multiple sclerosis starts a new prescription, baclofen, to control muscle spasticity. Three days later, the client calls the clinic nurse and reports feeling fatigued and dizzy. Which instruction should the nurse provide?

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client's plan of care?

A client who experiences migraine headaches reports having fewer headaches since using the herbal remedy feverfew. Which information is most important for the nurse to include in a teaching plan for this client?