A nurse is administering vancomycin to
a client who develops an infusion
reaction sometimes referred to as red
man syndrome. What action by the
nurse could have prevented this
reaction?
-Give the dose of vancomycin over 60 minutes
- Ask the client about allergy to antibiotics before
administering the medication. Watch for allergic
manifestations during and after the infusion.
What is the mechanism of action of a beta blocker? Name two
(2) contraindications for administering a beta blocker.
-when pulse is less than 60 beats per minute
-Patients with heart failure
A client is being discharged with clozapine. List two (2)
teaching points the nurse will discuss with the client
about this medication.
-if you develop difficulty controlling body movements
or blurry vision, report to the provider
-Change positions slowly from sitting to standing
position because it may cause dizziness
The nurse has provided teaching to a client about
alendronate. What statements would the nurse expect
to hear from the client that indicates understanding
about alendronate?
-take the medication on an empty stomach
-Used to treat osteoporosis
The nurse is caring for a client with cancer who has a
fentanyl patch. List one (1) priority finding that should
be reported to the provider.
-Shortness of breath, slowed breathing
Identify three (3) postoperative complications the
nurse will monitor for during the first two hours after
the procedure.
-Shock
, -Infection of surgical site
- DVT
The nurse is performing an admission health history in
the preoperative area of an ambulatory surgery
center. What client finding would indicate a potential
latex allergy?
-A patient who is allergic to bananas, kiwi, and avacados
When planning care for a client with a gambling
disorder, what teaching should be provided?
-Encourage patient to use a 12-step program
A nurse is taking care of a client postangiography. What
position should the client be placed in immediately after
this procedure?
-Bed rest in supine position, keep leg straight
A nurse is caring for a client with a chest tube and suspects
a subsequent pneumothorax upon assessment. List
three (3) clinical manifestations of a tension
pneumothorax.
-Breath sounds are absent
-Trachea is deviates away from the affected side
-Jugular venous distension, decreased cardiac output
A nurse is completing an assessment of a client with a
chest tube in place. The nurse notes crepitus around
the insertion site of the chest tube. What has caused
this to occur?
-Development of crepitus can indicate a small air leak
into the subcutaneous tissue and may indicate a need
for adjustment
A client was found unresponsive and brought into the
emergency department due to dehydration. List three
(3) labs that will reflect evidence of fluid volume deficit
the nurse will monitor.
-Elevated urine specific gravity
a client who develops an infusion
reaction sometimes referred to as red
man syndrome. What action by the
nurse could have prevented this
reaction?
-Give the dose of vancomycin over 60 minutes
- Ask the client about allergy to antibiotics before
administering the medication. Watch for allergic
manifestations during and after the infusion.
What is the mechanism of action of a beta blocker? Name two
(2) contraindications for administering a beta blocker.
-when pulse is less than 60 beats per minute
-Patients with heart failure
A client is being discharged with clozapine. List two (2)
teaching points the nurse will discuss with the client
about this medication.
-if you develop difficulty controlling body movements
or blurry vision, report to the provider
-Change positions slowly from sitting to standing
position because it may cause dizziness
The nurse has provided teaching to a client about
alendronate. What statements would the nurse expect
to hear from the client that indicates understanding
about alendronate?
-take the medication on an empty stomach
-Used to treat osteoporosis
The nurse is caring for a client with cancer who has a
fentanyl patch. List one (1) priority finding that should
be reported to the provider.
-Shortness of breath, slowed breathing
Identify three (3) postoperative complications the
nurse will monitor for during the first two hours after
the procedure.
-Shock
, -Infection of surgical site
- DVT
The nurse is performing an admission health history in
the preoperative area of an ambulatory surgery
center. What client finding would indicate a potential
latex allergy?
-A patient who is allergic to bananas, kiwi, and avacados
When planning care for a client with a gambling
disorder, what teaching should be provided?
-Encourage patient to use a 12-step program
A nurse is taking care of a client postangiography. What
position should the client be placed in immediately after
this procedure?
-Bed rest in supine position, keep leg straight
A nurse is caring for a client with a chest tube and suspects
a subsequent pneumothorax upon assessment. List
three (3) clinical manifestations of a tension
pneumothorax.
-Breath sounds are absent
-Trachea is deviates away from the affected side
-Jugular venous distension, decreased cardiac output
A nurse is completing an assessment of a client with a
chest tube in place. The nurse notes crepitus around
the insertion site of the chest tube. What has caused
this to occur?
-Development of crepitus can indicate a small air leak
into the subcutaneous tissue and may indicate a need
for adjustment
A client was found unresponsive and brought into the
emergency department due to dehydration. List three
(3) labs that will reflect evidence of fluid volume deficit
the nurse will monitor.
-Elevated urine specific gravity
