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Scenario

A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the client's condition evolves and whether it worsens or improves.

1500 hrs - Follow-Up Assessment

Exhibits

Based on the 1500 hrs assessment, categorize the following actions for the client.

A.

Increasing IV fluid rate

B.

Encouraging the client to sit up without assistance

C.

Administering antiemetic medication

D.

Monitoring respiratory rate closely

E.

Providing reassurance and calming interventions

F.

Checking electrolyte levels regularly

Answer and Explanation

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

 

Action

Essential

Nonessential

Contraindicated

 

Increasing IV fluid rate

 

The current rate is prescribed by the provider; increasing it without further assessment could lead to complications.

Encouraging the client to sit up without assistance

 

The client feels faint upon sitting up and is unsteady, so this could be dangerous.

Administering antiemetic medication

Helpful but not immediately critical.

 

Monitoring respiratory rate closely

Crucial due to client's rapid breathing and anxiety.

 

 

Providing reassurance and calming interventions

Important due to client's anxiety and discomfort.

 

 

Checking electrolyte levels regularly

Essential for ongoing monitoring given the client's symptoms.

 

 

Essential

  1. Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.

  2. Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.

  3. Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.

Nonessential

  1. Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.

Contraindicated

  1. Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.

  2. Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale

Propranolol is sometimes used to prevent migraines, so a history of migraines would not typically be a contraindication.

Choice B rationale

Hypothyroidism is not typically a contraindication for propranolol. However, propranolol can affect the metabolism of thyroid hormones and may mask signs of hyperthyroidism.

Choice C rationale

Propranolol is often used to treat hypertension, so a history of hypertension would not typically be a contraindication.

Choice D rationale

Propranolol is a non-selective beta-blocker, which means it blocks beta receptors in both the heart and the lungs. This can potentially cause bronchoconstriction and exacerbate asthma symptoms, so it should be used with caution in patients with a history of bronchial asthma.

Correct Answer is A

Explanation

Choice A rationale

The hospital pharmacist is the most appropriate resource for a nurse to consult for information on medication compatibility. Pharmacists have specialized knowledge and access to resources that provide information on drug interactions, including those between ampicillin and gentamicin sulfate. They can provide accurate and up-to-date information on whether these two medications can be safely administered together.

Choice B rationale

While the health care provider prescribes the medication, they may not have the most current or detailed information on drug compatibility. It is the pharmacist’s role to have this specialized knowledge.

Choice C rationale

Medication sales representatives are primarily focused on promoting their company’s products. They may not have comprehensive knowledge of drug interactions, especially between drugs from different companies.

Choice D rationale

The nurse manager oversees the nursing staff and coordinates care, but they may not have specific knowledge about all drug interactions. The hospital pharmacist is the most appropriate resource for this information.

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