Patient Data

Exhibits

Review H and P, and nurse’s note. Identify from the choices below which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Methemoglobinemia

Methemoglobinemia is a condition in which the hemoglobin in the blood is unable to bind oxygen effectively, resulting in tissue hypoxia. It can be caused by exposure to certain drugs or chemicals, such as nitrates, benzocaine, or dapsone. Some symptoms of methemoglobinemia include cyanosis, headache, fatigue, dyspnea, and tachycardia. In severe cases, it can lead to seizures, coma, and death.

Actions to Take:

Draw blood for a complete blood count
administer methylene blue

A complete blood count (CBC) can help diagnose methemoglobinemia by measuring the level of methemoglobin in the blood. A normal level is less than 1%, while a level above 15% can cause symptoms. A level above 30% can be life-threatening. Methylene blue is a medication that can reduce methemoglobin back to normal hemoglobin and restore oxygen delivery to the tissues. It is given intravenously at a dose of 1-2 mg/kg over 5 minutes.

Parameters to Monitor:

Methemoglobin level
heart rate and rhythm

The methemoglobin level is the most important parameter to monitor in methemoglobinemia, as it indicates the severity of the condition and the response to treatment. The goal is to lower the level below 10% or until symptoms resolve. The heart rate and rhythm are also important to monitor, as methemoglobinemia can cause tachycardia and dysrhythmias due to hypoxia and acidosis. The goal is to maintain a normal sinus rhythm and a heart rate within the normal range for the client’s age and condition.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Hard candy can be used for a dry mouth, which is a common side effect of St. John's wort.

Choice B reason: Another form of contraception is needed, because St. John's wort can reduce the effectiveness of oral contraceptives and increase the risk of unplanned pregnancy. This information requires further instruction from the nurse.

Choice C reason: Insomnia may occur while taking the medication, which is another possible side effect of St. John's wort. The client should be advised to take the medication in the morning or afternoon, and avoid caffeine and alcohol.

Choice D reason: Sensitivity to the sun can develop, which is a rare but serious side effect of St. John's wort. The client should be instructed to wear sunscreen and protective clothing when exposed to sunlight.

A. Promotes stomach emptying and prevents gastric reflux. B. Buffers hydrochloric acid and prevents gastric erosion. C. Prevents indigestion associated with ingestion of spicy foods. D. Binds with phosphorus in foods and prevents absorption.

Correct Answer is D

Explanation

Choice A reason: Promoting stomach emptying and preventing gastric reflux is not a relevant action of sevelamer, which is a phosphate binder that lowers serum phosphate levels in patients with CKD. Gastric reflux may be caused by other factors, such as hiatal hernia, obesity, or spicy foods.

Choice B reason: Buffering hydrochloric acid and preventing gastric erosion is not a pertinent action of sevelamer, which does not affect gastric acidity or mucosal integrity. Gastric erosion may be caused by other factors, such as NSAIDs, alcohol, or Helicobacter pylori infection.

Choice C reason: Preventing indigestion associated with ingestion of spicy foods is not a significant action of sevelamer, which does not affect digestion or food tolerance. Indigestion may be caused by other factors, such as overeating, stress, or gallstones.

Choice D reason: Binding with phosphorus in foods and preventing absorption is the correct action of sevelamer, which should be taken with meals to reduce the amount of phosphorus that enters the bloodstream from the diet. High serum phosphate levels can cause bone loss, calcification of soft tissues, and secondary hyperparathyroidism in patients with CKD.

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Patient Data Exhibits Review H and P, and nurse’s note. Identify from the choices below which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client with mild depression reports to the nurse recently starting St. John's wort. Which information provided by the client requires further instruction?

Correct Answer is B

Explanation

The nurse is administering sevelamer during lunch to a client with chronic kidney disease (CKD). The client asks the nurse to bring the medication later. The nurse should describe which action of sevelamer as an explanation for taking it with meals?

Correct Answer is D

Explanation

Which assessment finding requires nursing intervention prior to the administration of a prescribed dose of digoxin to an adult?

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 with bipolar disorder admitted with severe depression and suicidal ideation receives a prescription for lithium carbonate. Which instruction should the nurse provide to the client?

A client with multiple sclerosis starts a new prescription, baclofen, to control muscle spasticity. Three days later, the client calls the clinic nurse and reports feeling fatigued and dizzy. Which instruction should the nurse provide?

A client with bipolar disorder admitted with severe depression and suicidal ideation receives a prescription for lithium carbonate. Which instruction should the nurse provide to the client?

Patient Data Exhibits The charge nurse places a fall precautions sign on the client's door. What side effects of morphine could contribute to this client's fall risk? Select all that apply.