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.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A reason: Depression screening is not directly related to the effectiveness of orlistat, which is a medication that blocks the absorption of fat from the diet and helps to reduce weight. Depression screening may be important for the overall mental health of the client, but it is not an ongoing assessment for orlistat.

Choice B reason: Body mass index (BMI) is a measure of body fat based on height and weight, and it is used to assess the risk of obesity-related health problems. BMI is an ongoing assessment for orlistat, because it can indicate the progress and outcome of the weight management program. The goal of orlistat therapy is to achieve and maintain a healthy BMI.

Choice C reason: Daily calorie count is not an ongoing assessment for orlistat, because it does not reflect the amount of fat absorbed by the body. Orlistat works by blocking the action of lipase, an enzyme that breaks down fat in the intestine. Therefore, even if the client consumes a high-calorie diet, orlistat can prevent some of the fat from being absorbed and reduce weight. However, daily calorie count may be useful for monitoring the overall nutritional intake and energy balance of the client.

Choice D reason: Serum protein levels are not an ongoing assessment for orlistat, because they are not affected by the medication. Orlistat only blocks the absorption of fat, not protein or carbohydrates. Serum protein levels may be important for evaluating the nutritional status and organ function of the client, but they are not an indicator of orlistat effectiveness.

A. Sleeps soundly through the night. B. Decreased episodes of incontinence. C. Improved ability to concentrate. D. Exhibits fewer emotional outbursts.

Correct Answer is A

Explanation

Choice A reason: Sleeping soundly through the night is the desired outcome of administering zolpidem, which is a sedative-hypnotic that induces sleep by enhancing the activity of GABA, an inhibitory neurotransmitter. Zolpidem is used to treat insomnia, especially difficulty falling asleep.

Choice B reason: Decreasing episodes of incontinence is not a relevant outcome of administering zolpidem, which does not affect urinary function or bladder control. Incontinence may be caused by other factors, such as aging, prostate problems, or urinary tract infections.

Choice C reason: Improving ability to concentrate is not a pertinent outcome of administering zolpidem, which does not affect cognitive function or attention span. Zolpidem may actually impair memory and cause daytime drowsiness or confusion in some patients.

Choice D reason: Exhibiting fewer emotional outbursts is not a significant outcome of administering zolpidem, which does not affect mood or behavior. Zolpidem may actually cause paradoxical reactions, such as agitation, aggression, or hallucinations in some patients.

: [Zolpidem (Oral Route)]

: [Insomnia]

: [Urinary Incontinence]

: [Concentration Problems]

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

When administering zolpidem to an older client, which computer documentation indicates that the desired outcome has been achieved?

Correct Answer is A

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?

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?

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?

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 who is taking an oral dose of a tetracycline reports gastrointestinal (GI) upset. Which snack should the nurse instruct the client to take with the tetracycline?

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

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