Exhibits
The nurse is evaluating the client's progress and nursing implementations.
Click to high light the findings that would indicate the client has recovered from the adverse drug reaction.
1230:
Shaking is lessened. Client is no longer flushed. No longer itching. Anxiety has decreased. Skin warm and dry. Heart rate 62 beats/minute, blood pressure 130/72 mm Hg. No chest pain noted. Respirations are even and unlabored. Drowsy.
Shaking is lessened
Client is no longer flushed
No longer itching
Anxiety has decreased
Skin warm and dry
Heart rate 62 beats/minute, blood pressure 130/72 mm Hg
No chest pain noted
Respirations are even and unlabored
Drowsy
The Correct Answer is ["A","B","C","D","E","F","G","H","I"]
- Shaking is lessened: Shaking or tremors can be a manifestation of the body's response to stress or discomfort. A decrease in shaking suggests that the client's physiological response is returning to normal, indicating improvement.
- Client is no longer flushed: Flushing, or the reddening of the skin, can occur as a result of vasodilation during an allergic reaction or due to increased blood flow associated with elevated body temperature. The absence of flushing suggests that the body's inflammatory response has subsided, indicating resolution of the adverse reaction.
- No longer itching: Itching, or pruritus, is a common symptom of allergic reactions mediated by histamine release. The cessation of itching suggests that the inflammatory mediators responsible for the itching response have been cleared from the body, indicating resolution of the allergic reaction.
- Anxiety has decreased: Anxiety can be a psychological response to physical discomfort or distress. A decrease in anxiety levels suggests that the client is experiencing less discomfort and is psychologically improving, which can be indicative of recovery from the adverse drug reaction.
- Skin warm and dry: Warm and dry skin is a sign of normal thermoregulation and hydration status. The presence of warm and dry skin suggests that the client's body temperature and hydration levels are within normal limits, indicating physiological stability and recovery from the adverse drug reaction.
- Heart rate 62 beats/minute, blood pressure 130/72 mm Hg: Vital signs within normal limits, including a heart rate and blood pressure within the client's baseline range, indicate stability of cardiovascular function and resolution of any hemodynamic instability associated with the adverse drug reaction.
- No chest pain noted: Chest pain can be indicative of cardiovascular compromise or ischemia. The absence of chest pain suggests that the client's cardiovascular function has normalized, further supporting recovery from the adverse drug reaction.
- Respirations are even and unlabored: Even and unlabored respirations indicate normal respiratory function and adequate gas exchange. The absence of respiratory distress or effort suggests resolution of any respiratory complications associated with the adverse drug reaction.
- Drowsy: Drowsiness can be a side effect of medications such as antihistamines or a natural response to the body's recovery process. While drowsiness may persist for a period after the adverse drug reaction resolves, its presence alongside other signs of improvement suggests that the client's body is returning to a state of equilibrium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6.8"]
Explanation
Converting the weight to kg:
Client weight = 198 lbs 1 lb = 0.453592 kg
Client weight in kg = 198 lbs 0.453592 kg/lb = 90.7 kg
Calculating the desired dopamine infusion rate:
Dose = 2 mcg/kg/minute Client weight = 90.7 kg
Desired infusion rate = Dose Client weight = 2 mcg/kg/minute 90.7 kg = 181.4 mcg/minute
Determining the dopamine concentration in the bag:
Dopamine amount = 400 mg Bag volume = 250 mL
Dopamine concentration = Dopamine amount / Bag volume = 400 mg / 250 mL = 1.6 mg/mL
Convert mg/mL to mcg/mL: 1.6 mg/mL 1000 mcg/mg = 1600 mcg/mL
Calculating the rate in mL/minute:
Desired infusion rate = 181.4 mcg/minute Dopamine concentration = 1600 mcg/mL
Rate (mL/minute) = Desired infusion rate (mcg/minute) / Dopamine concentration (mcg/mL)
Rate = 181.4 mcg/minute / 1600 mcg/mL = 0.1134 mL/minute
Converting the rate to mL/hour:
Rate (mL/minute) = 0.1134 mL/minute Conversion factor: 60 minutes/hour
Rate (mL/hour) = 0.1134 mL/minute 60 minutes/hour = 6.8 mL/hour (round to nearest tenth)
Therefore, the nurse should set the IV pump to deliver approximately 6.8 mL/hour.
Correct Answer is D
Explanation
A. Verify the prothrombin time (PT).
While it is important to verify coagulation status in patients with atrial fibrillation to ensure they are not at high risk for bleeding, this is not the most critical step immediately prior to
cardioversion. The PT is more relevant if anticoagulation therapy is being managed.
B. Administer prescribed sedative.
Administering a sedative is important for patient comfort during the procedure, but it is not the most critical step that directly affects the success and safety of the cardioversion itself.
C. Select a monitor lead with a tall R wave.
Selecting a monitor lead with a tall R wave helps in accurately synchronizing the cardioversion shock with the R wave, but this is secondary to activating the synchronization mode which is critical to avoid delivering a shock during the vulnerable period of the cardiac cycle.
D. Activate the synchronization mode.
This is the correct answer. The most important action before deploying the current for cardioversion is to ensure the defibrillator is in synchronization mode. Synchronization ensures that the electrical shock is delivered at the correct time during the cardiac cycle, specifically on the R wave of the QRS complex, to avoid inducing ventricular fibrillation. This is crucial for
patient safety.
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