Patient Data

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 is experiencing
dropdown
and the blood pressure changes are the result of
dropdown
.

Answer and Explanation

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

Choice A: Syncope

Reason: Syncope, or fainting, is a temporary loss of consciousness typically caused by a drop in blood flow to the brain. The client has a history of symptomatic bradycardia, which is a slow heart rate that can lead to insufficient blood flow and oxygen to the brain, causing syncope. The client reported passing out once due to a low heart rate, which aligns with the symptoms of syncope. Bradycardia can cause a significant drop in cardiac output, leading to decreased cerebral perfusion and resulting in fainting episodes.

Choice B: Hypovolemic Shock

Reason: Hypovolemic shock occurs when there is a significant loss of blood or fluids, leading to decreased blood volume and inadequate tissue perfusion. Symptoms include rapid heartbeat, low blood pressure, and confusion. However, the client’s history and current condition do not indicate any significant blood or fluid loss. The primary issue is related to the heart’s electrical activity and rate, not volume loss.

Choice C: Heart Failure

Reason: Heart failure is a condition where the heart cannot pump blood effectively, leading to symptoms like shortness of breath, fatigue, and fluid retention. While the client has a history of atrial fibrillation, which can contribute to heart failure, the immediate concern is the symptomatic bradycardia causing syncope. The client’s symptoms of low heart rate and fainting are more directly related to bradycardia rather than heart failure.

Choice D: Adverse Drug Reaction

Reason: An adverse drug reaction could cause various symptoms, including changes in heart rate and blood pressure. However, the client has not reported any new medications or changes in her current regimen that would suggest an adverse reaction. The symptoms described are consistent with her known condition of bradycardia.

Choice A: Anxiety

Reason: Anxiety can cause various physiological responses, including increased heart rate and blood pressure. However, the client’s primary issue is a low heart rate, which is not typically associated with anxiety. Anxiety might exacerbate symptoms but is not the root cause of the blood pressure changes in this case.

Choice B: Antibiotic

Reason: While antibiotics can cause side effects, they are not typically associated with significant changes in blood pressure. The vancomycin administered was for endocarditis prophylaxis and is unlikely to be the cause of the blood pressure changes observed.

Choice C: IV Infiltration

Reason: IV infiltration occurs when IV fluids leak into the surrounding tissue, causing swelling, pain, and potential tissue damage. While this can cause localized issues, it is not typically associated with systemic blood pressure changes. The client’s symptoms are more consistent with a systemic issue related to her heart condition.

Choice D: Vasodilation

Reason: Vasodilation refers to the widening of blood vessels, which can lead to a drop in blood pressure. This can occur as a response to various factors, including medications, heat, or a physiological response to low blood flow. In the context of bradycardia, the body’s compensatory mechanisms might include vasodilation to improve blood flow, which can result in lower blood pressure.

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Correct Answer is D

Explanation

Choice A Reason:

Polyuria, or excessive urination, is a symptom of diabetes insipidus rather than a side effect of vasopressin. Vasopressin is used to reduce urine output in DI patients. If polyuria persists, it may indicate that the medication is not effective, but it is not a direct side effect that requires immediate reporting.

Choice B Reason:

Low urine specific gravity indicates dilute urine, which is a characteristic of diabetes insipidus. Vasopressin should help concentrate the urine. If low urine specific gravity persists, it may suggest that the medication is not working effectively, but it is not a side effect that necessitates urgent reporting.

Choice C Reason:

Polydipsia, or excessive thirst, is another symptom of diabetes insipidus. While vasopressin should help reduce this symptom by controlling urine output, persistent polydipsia may indicate inadequate treatment. However, it is not a side effect of the medication that requires immediate attention.

Choice D Reason:

Worsening headache is a significant side effect that should be reported to the healthcare provider. Headaches can indicate water intoxication or hyponatremia (low sodium levels), which are serious complications of vasopressin therapy. Immediate reporting is necessary to adjust the treatment and prevent further complications.

A. No known allergies B. Dosage in safe range C. Potassium 4.4 mEq/L (4.4 mmol/L) D. Peripheral IV in large vein E. Used for prophylaxis F. Blood urea nitrogen 17 mg/dl (6.07 mmol/L)

Correct Answer is ["A","B","D","E"]

Explanation

Choice A: No known allergies

Reason: The absence of known allergies is crucial when administering any medication, including antibiotics like vancomycin. Allergic reactions to antibiotics can range from mild rashes to severe anaphylaxis, which can be life-threatening. In this case, the patient has reported no known allergies, which significantly reduces the risk of an adverse reaction to vancomycin. This makes it safer to proceed with the administration of the antibiotic. Ensuring that the patient has no known allergies is a standard precaution in medical practice to prevent potential allergic reactions.

Choice B: Dosage in safe range

Reason: The dosage of vancomycin must be within a safe range to avoid toxicity. Vancomycin is typically dosed based on the patient’s weight and renal function. For adults, the usual dose is 15-20 mg/kg, administered every 8-12 hours, depending on the severity of the infection and the patient’s renal function. In this scenario, the prescribed dose is 1 gram in 250 mL of 0.9% sodium chloride, which is within the safe range for an adult patient. Administering the correct dosage is essential to ensure the effectiveness of the antibiotic while minimizing the risk of nephrotoxicity and ototoxicity, which are potential side effects of vancomycin.

Choice C: Potassium 4.4 mEq/L (4.4 mmol/L)

Reason: While the potassium level of 4.4 mEq/L is within the normal range (3.5-5.0 mEq/L), it is not directly related to the safety of administering vancomycin. Potassium levels are more relevant to the overall electrolyte balance and cardiac function but do not specifically impact the administration of vancomycin. Therefore, this choice is not as pertinent to the safety of vancomycin administration as the other options.

Choice D: Peripheral IV in large vein

Reason: Administering vancomycin through a peripheral IV in a large vein is important to reduce the risk of phlebitis and irritation. Vancomycin is known to be irritating to veins, and using a large vein helps to dilute the medication more effectively, reducing the risk of vein inflammation. In this case, the peripheral IV was started in the right antecubital with a 20-gauge catheter, which is appropriate for the administration of vancomycin. Ensuring proper IV placement and using a large vein can help prevent complications associated with IV administration of this antibiotic.

Choice E: Used for prophylaxis

Reason: Vancomycin is being used as a prophylactic measure to prevent endocarditis in this patient. Prophylactic use of antibiotics is common in patients undergoing certain surgical procedures, especially those with a history of heart conditions, to prevent bacterial infections. In this case, the patient is undergoing pacemaker insertion, and the use of vancomycin as prophylaxis is appropriate to prevent potential infections. Prophylactic administration of antibiotics like vancomycin is a standard practice to reduce the risk of postoperative infections, particularly in patients with a higher risk of complications.

Choice F: Blood urea nitrogen 17 mg/dl (6.07 mmol/L)

Reason: The blood urea nitrogen (BUN) level of 17 mg/dL is within the normal range (7-20 mg/dL). While BUN levels are important indicators of renal function, they are not directly related to the safety of administering vancomycin in this context. Vancomycin dosing does need to consider renal function, but the BUN level alone does not provide sufficient information to determine the safety of administration. Therefore, this choice is not as directly relevant as the other options.

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Naxlex Comprehensive Predictor Exams

A client who is newly diagnosed with diabetes insipidus (DI) is receiving synthetic vasopressin intravenously. Which side effect of vasopressin reported by the client should the nurse report to the healthcare provider?

Correct Answer is D

Explanation

Patient Data Exhibits The nurse is preparing the client’s plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

Correct Answer is ["A","B","D","E"]

Explanation

The healthcare provider prescribes magnesium sulfate 300 mg/hour IV. The IV bag contains magnesium sulfate 4 grams in dextrose 5% in water (D5W) 500 mL. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

After receiving the third dose of a new oral anticoagulant prescription, an older adult client develops bleeding and tender gums and has many new bruises. Which actions should the nurse implement? Select all that apply.

Patient Data Exhibits The healthcare provider (HCP) has given the client a prescription for captopril. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Captopril is a(n) dropdown that works by dropdown.

A client with nasal congestion receives a prescription for phenylephrine 10 mg PO every 4 hours. Which client condition should the nurse report to the healthcare provider before administering the medication?

A client with a fungal infection of the toenail reports to the nurse that the client has been applying an over-the-counter (OTC) triple antibiotic ointment to the infection daily for two weeks without any improvement. Which action should the nurse take?

A client is receiving orlistat as part of a weight management program. Which ongoing assessment should be included in the plan of care to determine the effectiveness of the medication?

A client has a prescription for heparin 5000 units IV STAT. Several pre-filled syringes of low molecular weight heparin are available in the client’s medication drawer. Which action should the nurse implement?

The nurse is teaching a client how to use an inhaler device. Which client statement indicates to the nurse that the client understands the instructions?