Exhibits here
The nurse is implementing the plan of care.
For each body system, click to 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.
The Correct Answer is []
Immunological Administer antihistamine
The correct answer is to administer antihistamine. Antihistamines can help alleviate symptoms of an allergic reaction, such as itching, hives, and swelling, by blocking the effects of histamine
released during the allergic response.
Cardiovascular
Monitor vital signs continuously
The correct answer is to monitor vital signs continuously. Continuous monitoring of vital signs, including blood pressure, heart rate, and oxygen saturation, is essential to detect any changes in the client's cardiovascular status, especially after experiencing adverse reactions to medication.
Provide warmth
Providing warmth can help improve peripheral circulation and comfort for the client, especially if they are experiencing symptoms such as dizziness or feeling cold due to a drop in blood pressure.
Respiratory
Assess lung sounds
The correct answer is to assess lung sounds. Assessing lung sounds can help determine if the client is experiencing any respiratory distress or complications, such as wheezing or crackles, which may indicate a need for further intervention or respiratory support.
Chest x-ray
Ordering a chest x-ray can help evaluate the client's respiratory status, especially if there are concerns about potential complications such as pneumonia or pulmonary edema. It allows for the assessment of lung fields and can provide valuable information about the client's respiratory function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Aching leg. Aching leg is not a commonly occurring problem after gastric endoscopy. It may be related to positioning during the procedure or another unrelated issue.
B. Nausea. Nausea is a potential side effect of the anesthesia or sedation used during the procedure. However, it is not as commonly occurring as a sore throat after gastric endoscopy.
C. Sore throat. Sore throat is a commonly occurring problem after gastric endoscopy due to
irritation of the throat by the endoscope. It is often caused by the insertion and manipulation of the scope during the procedure.
D. Headache. While headache can occur as a side effect of anesthesia or sedation, it is not as commonly associated with gastric endoscopy as a sore throat.
Correct Answer is B
Explanation
A. Oxygen is less toxic when it is humidified with a hydration source. While humidification can prevent drying of the respiratory mucosa, it does not directly relate to the principle of avoiding high levels of oxygen for extended periods.
B. Avoid administration of oxygen at high levels for extended periods. This is the correct principle. Prolonged exposure to high levels of oxygen can lead to oxygen toxicity, which can cause lung damage. Oxygen therapy should be titrated to maintain adequate oxygenation without exposing the patient to excessive oxygen levels.
C. Increase oxygen rate during sleep to compensate for slower respiratory rate. This statement is incorrect. Oxygen therapy should be adjusted based on the patient's oxygen saturation levels and respiratory status, not solely on sleep patterns.
D. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs. While sedatives can depress respiratory rate, leading to decreased oxygen needs, this is not a general principle of oxygen administration. Oxygen therapy should be based on the patient's oxygenation needs rather than medications they are taking.
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