Exhibits
The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence.
The client is at immediate risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"B"}
A. anaphylaxis
The correct answer is A. Anaphylaxis is a severe, life-threatening allergic reaction that can occur in response to medication administration. The client's symptoms of dizziness, headache, burning feeling on extremities, and redness on face and extremities, along with the sudden onset of symptoms after starting vancomycin infusion, are indicative of a possible anaphylactic reaction.
B. arrhythmias
The correct answer is B. Arrhythmias refer to abnormal heart rhythms, which can be
triggered by various factors including medication reactions. Given the client's history of symptomatic bradycardia and the sudden onset of symptoms after starting vancomycin infusion, arrhythmias such as bradycardia or other rhythm disturbances are a concern.
C. Cardiac arrest
The correct answer is C. Cardiac arrest is the cessation of normal heart function, which can be precipitated by severe arrhythmias or anaphylaxis. The client's symptoms, along with the drop in blood pressure, indicate a potential risk of progressing to cardiac arrest if not promptly treated.
D. Necrosis
Necrosis, or tissue death, is not typically associated with the symptoms described in the scenario. While vancomycin infusion can potentially cause tissue irritation or damage at the
injection site, the symptoms described suggest a systemic reaction rather than localized tissue necrosis.
E. Renal failure
Renal failure is not directly indicated by the symptoms described in the scenario. While vancomycin can be nephrotoxic in some cases, the symptoms of dizziness, headache, and redness are more suggestive of an allergic or cardiovascular reaction.
F. Peripheral edema
Peripheral edema, or swelling in the extremities, is not indicated by the symptoms described in the scenario. The client's symptoms, such as dizziness, headache, and redness, are more
indicative of a systemic reaction rather than localized swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Instruct client and family to reconsider end of life choices.
This is not an appropriate intervention. In hospice care, the focus is on providing comfort and supporting the client’s and family’s current end-of-life choices rather than challenging them.
B. Encourage family to visit frequently.
Encouraging family visits can provide emotional support and comfort to the client, helping them cope with feelings related to death and dying.
C. Teach client how to use guided imagery.
Guided imagery can be a helpful technique for managing anxiety and emotional distress, offering the client a method to find peace and comfort.
D. Encourage family to bring the client old photographs.
Old photographs can help evoke positive memories and provide comfort, aiding the client in coping with feelings of death and dying.
E. Record the client's desire to live.
Recording the client's desires is important for documenting their wishes, but it is not an intervention that directly aids in coping with feelings related to death and dying.
Correct Answer is A
Explanation
A. Determining the type of chemical exposure is critical as it guides subsequent treatment and interventions. Different chemicals require different management strategies, including whether to induce vomiting or administer activated charcoal.
B. Calling poison control is important but should occur after identifying the specific chemical involved, as the poison control guidelines often depend on the substance the child was exposed to.
C. Assessing for altered sensorium is important, but the immediate priority is to identify the type of chemical exposure to implement appropriate interventions.
D. Obtaining equipment for gastric lavage may be necessary in certain cases, but this is based on the type of chemical ingested and the child's condition. Identifying the chemical exposure must occur first to determine if gastric lavage is appropriate.
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