Which of these findings, from a client taking steroids, should the nurse report immediately?
Temperature of 101.2 degrees Fahrenheit
Blood pressure of 144/68 mm Hg
Glucose 128 mg/dl
Heart rate of 102 beats per minute
The Correct Answer is A
a) An elevated temperature could indicate an infection, which is a serious concern in a client taking steroids, as steroids can suppress the immune system. This finding should be reported immediately.
b) Blood pressure within this range is generally acceptable and may not be a cause for immediate concern.
c) A glucose level of 128 mg/dl is within a reasonable range and may not require immediate reporting unless there are other concerning factors.
d) A heart rate of 102 beats per minute is generally within an acceptable range and may not be an immediate cause for concern in the absence of other symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Elevated temperature is not a typical reason to withhold morphine unless there are other concerns, such as infection.
B) Elevated blood pressure alone is not a reason to withhold morphine, but it should be considered in the context of the overall clinical picture.
C) A respiratory rate of 10 breaths per minute with low oxygen saturation indicates respiratory depression, which is a significant concern and a reason to withhold morphine.
D) An elevated heart rate alone is not a reason to withhold morphine, but it should be considered in the context of the overall clinical picture.
Correct Answer is B
Explanation
a) Stopping all antibiotics and implementing strict use of alcohol-based hand sanitizer is not the appropriate response to the observed symptoms. The focus should be on addressing the potential infection.
b) The symptoms suggest the possibility of Clostridium difficile infection, and discontinuing the cephalosporin is crucial. Vancomycin or metronidazole is commonly used to treat C. difficile infection.
c) Requesting an additional antibiotic to override the effects of the cephalosporin is not the appropriate course of action. The focus should be on discontinuing the causative antibiotic.
d) Increasing the dose of cephalosporin is contraindicated in the presence of suspected C. difficile infection. Isolation measures may be implemented, but the priority is discontinuing the causative antibiotic and initiating appropriate treatment for the infection.
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