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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

, and the blood pressure changes are the result of

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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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

  • Give insulin lispro 4 units: Contraindicated - Insulin lispro is a rapid-acting insulin that should be given in relation to meal intake. Since the client's meal tray has not arrived, administering insulin lispro could lead to hypoglycemia.
  • Verify that the client can count carbohydrates: Nonessential - While it’s useful to know if a client can count carbohydrates, it’s not critical for administering scheduled long-acting insulin like insulin glargine.
  • Mix the insulin lispro and insulin glargine in one syringe: Contraindicated - Insulin glargine is a long-acting insulin and should not be mixed with other insulins in the same syringe.
  • Give insulin glargine 12 units: Indicated - Insulin glargine is a long-acting insulin that is typically given at a set time each day and is not dependent on immediate food intake, so it is appropriate to administer the scheduled dose.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"},"G":{"answers":"C"}}

Explanation

1. Dizziness while sitting up: Non-therapeutic side effect

- Dizziness is a common side effect of minoxidil, often due to the vasodilatory effects, which can cause orthostatic hypotension.

2. Blood glucose 218 mg/dL: Unrelated finding

- Elevated blood glucose is unrelated to minoxidil administration and is more likely related to the client's diabetes.

3. Mouth dryness: Non-therapeutic side effect

- Dry mouth can be a side effect of minoxidil, though it is not a common one.

4. Blood pressure 162/111 mmHg: Therapeutic result

- The reduction in blood pressure from 203/166 mmHg to 162/111 mmHg is a therapeutic effect of minoxidil, which is used to lower blood pressure.

5. Heart rate 99: Non-therapeutic side effect

- Tachycardia can be a side effect of minoxidil, as it can lead to reflex tachycardia due to its vasodilatory effects.

6. Pain of 1 out of 10: Unrelated finding

- The reduction in pain is unrelated to the administration of minoxidil and is likely due to the ibuprofen given for pain management.

7. Urine output 600 mL: Unrelated finding

- Urine output is not directly related to the administration of minoxidil and is not typically affected by the drug.

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