The nurse is caring for a client who has a finger stick blood glucose level of 130 mg/dL (7.21 mmol/L). Prior to administering the scheduled dose of acarbose, the nurse is informed that morning meal trays will be 30 minutes late. Which action should the nurse take?Reference Range:
Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Notify the healthcare provider.

Administer the medication.

Hold the medication until the meal trays arrive.

Obtain another finger stick blood glucose level.

Answer and Explanation

The Correct Answer is C

A. Notify the healthcare provider: Notification of the healthcare provider is not immediately necessary just because of a meal delay. The nurse can manage the situation appropriately by adjusting the medication timing to ensure patient safety without requiring immediate provider involvement.

B. Administer the medication: Acarbose should be taken with the first bite of food to effectively delay carbohydrate absorption. Administering it without food available increases the risk of hypoglycemia, especially since the glucose level is already slightly elevated but within a manageable range.

C. Hold the medication until the meal trays arrive: Acarbose must be taken with the first mouthful of food to match the timing of glucose absorption. Holding the medication until the meal arrives ensures optimal therapeutic effect and prevents unnecessary hypoglycemia.

D. Obtain another finger stick blood glucose level: Rechecking the blood glucose is unnecessary at this time. The primary concern is coordinating the medication with food intake, not monitoring glucose trends over a short 30-minute delay.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is []

Explanation

Methemoglobinemia: Methemoglobinemia is characterized by hypoxia symptoms despite normal oxygen saturation readings. However, this condition is very rare in asthma patients and is typically associated with certain medications or chemical exposures, not beta-agonist overuse like albuterol.
Anemia: Anemia could cause dizziness and lightheadedness, but it would not explain palpitations triggered by excessive albuterol use. The acute worsening of symptoms with a background of asthma and heavy beta-agonist use points away from anemia as the primary concern.
Anaphylaxis: Anaphylaxis presents with airway swelling, hypotension, wheezing, and respiratory compromise. Since the client’s oxygen saturation is excellent (99%) and no wheezing or airway edema is noted, anaphylaxis is unlikely in this scenario.
Tachydysrhythmia: Tachydysrhythmia is the most likely diagnosis because overuse of albuterol stimulates beta receptors, leading to increased heart rate, palpitations, dizziness, and lightheadedness. This aligns precisely with the client's reported symptoms and assessment findings.
Administer diphenhydramine: Diphenhydramine is an antihistamine used primarily for allergic reactions and anaphylaxis. There is no evidence of an allergic process in this client; thus, administering diphenhydramine would not address the cardiac symptoms from probable tachydysrhythmia.
Give a dose of albuterol: Administering more albuterol would likely worsen the tachydysrhythmia, as beta-agonists increase heart rate and myocardial oxygen demand. Since the problem stems from albuterol overuse, giving another dose would be inappropriate and harmful.
Take a set of baseline vital signs: Taking a set of baseline vital signs is essential because it provides a foundation for assessing current cardiovascular stability. It would help establish the severity of the tachycardia and guide further intervention strategies.
Place the client on a cardiorespiratory monitor: Placing the client on a cardiorespiratory monitor is critical to continuously assess heart rate, rhythm, and potential arrhythmias. This allows immediate detection of life-threatening patterns such as supraventricular tachycardia or ventricular ectopy.
Draw blood for a complete blood count: Drawing a CBC would help if there was suspicion of anemia or infection, but the clinical picture points primarily toward a cardiac rhythm problem. This diagnostic step would not be immediately necessary based on the current situation.
Methemoglobin level: Monitoring methemoglobin levels would be appropriate if the client had cyanosis or unexplained hypoxia without respiratory distress. Since the oxygen saturation is excellent, checking methemoglobin is not relevant to her current condition.
Iron level: Monitoring iron levels is important in diagnosing chronic anemia, but anemia is not the primary issue here. The focus should remain on cardiovascular monitoring because the immediate symptoms suggest arrhythmia rather than a hematologic cause.
Breath sounds: Although the client currently has no wheezing, regular assessment of breath sounds is necessary to detect any developing bronchospasm or respiratory deterioration, especially given her underlying asthma diagnosis and recent respiratory strain.
Airway edema: Monitoring for airway edema would be essential if anaphylaxis were suspected. Since there are no signs of respiratory distress, stridor, or swelling, airway edema monitoring is less relevant compared to cardiac monitoring in this situation.
Heart rate and rhythm: Heart rate and rhythm must be continuously monitored because the client is exhibiting signs of tachydysrhythmia. Detecting arrhythmias early enables prompt treatment and reduces the risk of serious cardiac complications like syncope or cardiac arrest.

A. Observe bowel movement pattern and take a stool softener. B. Do not drink grapefruit juice after taking morphine. C. Watch for signs of agitation and record any insomnia. D. Take the benzodiazepine at the same time of taking the morphine.

Correct Answer is A

Explanation

A. Observe bowel movement pattern and take a stool softener: Morphine commonly causes constipation due to reduced gastrointestinal motility. Recognizing this and taking preventive measures like a stool softener indicates a good understanding of how to manage one of the most frequent and bothersome side effects of opioid therapy.

B. Do not drink grapefruit juice after taking morphine: Grapefruit juice significantly interacts with certain medications, particularly those metabolized by CYP3A4 enzymes, but it has minimal clinical effect on morphine metabolism. This instruction is not relevant for morphine use.

C. Watch for signs of agitation and record any insomnia: While these symptoms can occasionally occur, they are not typical or expected side effects of morphine. More common effects include sedation, respiratory depression, and constipation.

D. Take the benzodiazepine at the same time of taking the morphine: Combining morphine with benzodiazepines increases the risk of severe sedation, respiratory depression, and overdose. Co-administration should be carefully managed and typically avoided unless specifically directed by the healthcare provider.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify 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.

Correct Answer is []

Explanation

The nurse is providing discharge instructions for a client with metastatic cancer who is prescribed morphine for bone pain. Which information from the client indicates to the nurse an understanding of the medication?

Correct Answer is A

Explanation

Patient Data Exhibits Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a nontherapeutic side effect, or an unrelated finding. Each row must have one option selected.

After receiving five doses of filgrastim, the nurse notes that the client's white blood cell count has increased from 2,500/mm3 (2.5 x 10 /L) to 5,000/mm3 (5 x 105/L). Which action should the nurse implement?Reference Range:White Blood Cell (WBC) [5,000 to 10,000/mm3 (5 to 10 x 109/L)]

When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. Which action should the nurse take?

A client with Parkinson's disease who is taking carbidopa/levodopa reports the urine appears to be darker in color. Which action should the nurse take?

A client diagnosed with myasthenia gravis receives a prescription for pyridostigmine. Which intervention should the nurse implement when preparing to administer this medication?

To control asthma, a client in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system, which provides an inhaled powdered form of these combined medications. Which instruction should the nurse provide to this client's caregivers?

The nurse is administering sucralfate to a client with stomatitis secondary to chemotherapy. The client wants to take the medication after breakfast. How should the nurse respond?

Patient Data Exhibits Click to mark whether the assessment finding represents a therapeutic result of the minoxidil administered, a nontherapeutic side effect, or an unrelated finding. Each row must have one option selected.