Patient Data

Exhibits

The nurse is implementing the plan of care.

For each body system, select 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.

Answer and Explanation

The Correct Answer is []

Body System: Respiratory

The correct choice is A

Choice A: Assess lung sounds This is the correct choice because the client may have developed an allergic reaction to vancomycin, which can cause bronchospasm and wheezing. Assessing lung sounds can help the nurse monitor the client’s respiratory status and intervene if needed.

Choice B: Provide a calm environment This is not the correct choice because providing a calm environment is not specific to the respiratory system. It may help the client feel more comfortable, but it does not address the potential respiratory complications of an allergic reaction.

Choice C: Pain medication This is not the correct choice because pain medication is not related to the respiratory system. The client did not report any pain, and pain medication may have adverse effects on the respiratory system, such as respiratory depression.

Choice D: Chest x-ray This is not the correct choice because a chest x-ray is not indicated for the client at this time. A chest x-ray is a diagnostic test that can show abnormalities in the lungs, such as pneumonia or pleural effusion. However, the client’s symptoms are more likely caused by an allergic reaction, which would not be visible on a chest x-ray.

Body System: Cardiovascular

The correct answer is A, B, and C. Here are the explanations for each choice:

Choice A: Monitor vital signs continuously. This is a correct and appropriate nursing intervention for the cardiovascular system. The client may have hypotension, tachycardia, or arrhythmias due to anaphylaxis or the effects of medications. Continuous monitoring can help detect any changes and guide interventions accordingly .

Choice B: Provide warmth. This is also a correct and appropriate nursing intervention for the cardiovascular system. The client may lose heat due to vasodilation, sweating, or exposure during the procedure. Providing warmth can help prevent hypothermia and shivering, which can increase oxygen demand and worsen cardiac function. Providing warmth can also improve comfort and reduce anxiety .

Choice C: Defibrillator at bedside. This is another correct and appropriate nursing intervention for the cardiovascular system. The client is at risk of cardiac arrest due to anaphylaxis, bradycardia, or pacemaker malfunction. Having a defibrillator at bedside can facilitate prompt resuscitation if needed.

Choice D: ECHO. This is an incorrect and inappropriate nursing intervention for the cardiovascular system. ECHO is a diagnostic test that uses ultrasound waves to create images of the heart and its structures. It can help evaluate the client’s cardiac function, valve function, and presence of any complications such as pericardial effusion or tamponade. However, this is not a priority intervention for the client who is experiencing an anaphylactic reaction and needs immediate treatment to stabilize her condition. ECHO can be done later after the client recovers from the acute episode.

Body System: Immunological

The correct answer is **A and D**.

- Choice A: Administer antihistamine. This is a correct and appropriate nursing intervention for the immunological system. The client is having an anaphylactic reaction to vancomycin, which is a type of hypersensitivity reaction mediated by IgE antibodies. Antihistamines, such as diphenhydramine, can block the effects of histamine, which is a major mediator of allergic inflammation and symptoms. Antihistamines can help reduce itching, hives, flushing, and bronchoconstriction¹².

- Choice B: IV fluids. This is an incorrect and inappropriate nursing intervention for the immunological system. IV fluids are not directly related to the immune response or the allergic reaction. IV fluids are mainly used to maintain hydration, electrolyte balance, and blood pressure. However, IV fluids may be indicated for the client as part of the cardiovascular or renal system interventions³.

- Choice C: Assess rash. This is an incorrect and inappropriate nursing intervention for the immunological system. Assessing rash is not a specific intervention for the immune response or the allergic reaction. Assessing rash is part of the general assessment of the client's skin condition, which may reflect other factors such as infection, inflammation, or drug toxicity. However, assessing rash may be helpful to monitor the severity and progression of the allergic reaction and the effectiveness of the treatment⁴.

- Choice D: Administer steroid. This is a correct and appropriate nursing intervention for the immunological system. The client is having an anaphylactic reaction to vancomycin, which is a type of hypersensitivity reaction mediated by IgE antibodies. Steroids, such as methylprednisolone, can suppress the immune system and reduce the production of inflammatory mediators, such as cytokines and prostaglandins. Steroids can help decrease swelling, inflammation, and tissue damage¹².

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Choice A reason: This statement indicates understanding of naloxone. Naloxone is an opioid antagonist that can reverse the effects of opioid overdose, such as respiratory depression, sedation, and hypotension. Naloxone can be administered by different routes, depending on the availability and urgency of the situation. Intravenous, intramuscular, and subcutaneous routes are all acceptable ways to give naloxone.

Choice B reason: This statement also indicates understanding of naloxone. Naloxone works best on pure agonist opioids, such as morphine, heroin, and fentanyl. These opioids bind to the same receptors as naloxone, but naloxone has a higher affinity and can displace them. Naloxone is less effective on partial agonist or mixed agonist-antagonist opioids, such as buprenorphine and pentazocine. These opioids have lower intrinsic activity or antagonize some receptors, making them less susceptible to naloxone.

Choice C reason: This statement indicates no understanding of naloxone. Naloxone is not a harmless drug that can be given repeatedly without consequences. Naloxone has a short half-life of about 30 to 90 minutes, which means it can wear off before the opioid does. This can cause the patient to relapse into respiratory depression and require repeated doses of naloxone. However, giving too many doses of naloxone can also cause adverse effects, such as agitation, hypertension, tachycardia, pulmonary edema, and seizures. Therefore, naloxone should be given cautiously and titrated to the minimum effective dose to reverse respiratory depression.

Choice D reason: This statement indicates no understanding of naloxone. Naloxone will affect the client's level of pain by blocking the analgesic effects of opioids. This can cause the patient to experience acute pain and distress, especially if they have a chronic pain condition or a surgical wound. Naloxone should not be used to treat opioid-induced sedation or pruritus without respiratory depression, as this will unnecessarily expose the patient to pain and suffering.

Choice E reason: This statement indicates no understanding of naloxone. When given IV, naloxone starts working immediately, but it does not last several hours. As mentioned earlier, naloxone has a short half-life and can be eliminated from the body quickly. The duration of action of naloxone depends on the dose, route, and frequency of administration, as well as the type, dose, and route of the opioid involved. Generally, naloxone lasts for about 30 to 90 minutes when given IV, which may not be enough to counteract the longer-lasting effects of some opioids. Therefore, continuous monitoring and repeated doses of naloxone may be needed until the opioid is cleared from the system.

A. Trouble sleeping B. Difficulty with urination C. Unexplained weight loss D. Recent oral intake

Correct Answer is D

Explanation

Choice A reason: Trouble sleeping is not a relevant information for administering pyridostigmine, which is a cholinesterase inhibitor that improves muscle strength and function in patients with myasthenia gravis. Trouble sleeping may be caused by other factors, such as stress, pain, or medication side effects.

Choice B reason: Difficulty with urination is not a pertinent information for administering pyridostigmine, which does not affect urinary function or bladder control. Difficulty with urination may indicate a urinary tract infection, prostate enlargement, or kidney stones.

Choice C reason: Unexplained weight loss is not a significant information for administering pyridostigmine, which does not affect metabolism or appetite. Unexplained weight loss may be a sign of an underlying condition, such as hyperthyroidism, diabetes, or cancer.

Choice D reason: Recent oral intake is the correct information for administering pyridostigmine, which should be taken on an empty stomach or before meals to enhance its absorption and effectiveness. Pyridostigmine can also help prevent or reduce dysphagia (difficulty swallowing), which is a common symptom of myasthenia gravis.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits For each statement, click to indicate whether the statements by the student nurse indicate understanding or no understanding of naloxone.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

Correct Answer is D

Explanation

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

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.

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?

The nurse is teaching a client with type 1 diabetes mellitus (DM) about the onset, peak, and duration of a new prescription for glargine insulin. If the insulin is administered at 0800, when is the client most likely to experience hypoglycemia?

Azithromycin is prescribed for a client with Chlamydia trachomatis. In providing client teaching about the medication, the nurse should emphasize the importance of reporting the onset of which symptom to the health care provider?

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.

A client receives a prescription for 500 mL of dextrose in 5% water intravenously (IV) to be infused over 3 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Patient Data Exhibits What actions should the nurse take to ensure safety during morphine administration? Select all that apply.