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The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

The nurse is caring for a client who takes methotrexate for rheumatoid arthritis and receives a prescription for adalimumab. Which instructions should the nurse provide the client?

The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?

Patient Data History and Physical The client is a 75-year-old female admitted to the preoperative area to prepare for pacemaker insertion. Client reports she is having this done because her heart rate has been staying very low. She is always tired, and she has passed out once from a low heart rate. Client has a history of worsening symptomatic bradycardia. History of atrial fibrillation controlled by medication. Has been off anticoagulants for 4 days to prepare for the procedure.

Nurses Notes 0700: Laboratory specimens have been drawn and completed during a preadmission visit. After changing clothes and settling into bed, the client was placed on continuous monitoring. Admission process completed. 0800: Peripheral IV (PIV) started in the right antecubital with a 20-gauge catheter. IV fluids of 0.9% sodium chloride started at 50 mL/hr. Cardiac surgeon in to see the client and answer questions about the procedure. 0830: Client reports no known allergies. Vancomycin 1 gram in 250 mL 0.9% sodium chloride started at 125 mL/hr as endocarditis prophylaxis. 0840: Awaiting transfer to the operating room (OR). Vancomycin infusing at 125 mL/hr. 0845: Client states, “I don’t feel well.” Assessment reveals dizziness, headache, burning feeling on extremities, and red color on face and extremities. Blood pressure 108/46 mm Hg. Vancomycin infusion stopped. Surgeon notified. 0850: Client has flushing and redness over the entire body with hives developing. Reports they are feeling hot and nauseous. Cool cloths to face and extremities. Unable to be still in bed. IV fluids of 0.9% sodium chloride infusing at 125 mL/hr. Blood pressure 100/50 mm Hg, heart rate 110 beats/minute. Surgeon to bedside. 0855: Continues with worsening symptoms. Diphenhydramine 25 mg given IV. 0900: Heart rate 90 beats/minute, blood pressure 110/60 mm Hg. Surgeon remains at bedside.

The nurse is evaluating the client’s progress and nursing implementations. Bold the words to highlight the findings that would indicate the client has recovered from the adverse drug reaction.

1230:

The nurse is providing discharge instructions to a client who has been prescribed gabapentin 300 mg by mouth (PO) three times a day for postherpetic neuralgia. Which symptom should the nurse tell the client to report to the healthcare provider?

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?

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?

A client who is taking dextroamphetamine-amphetamine extended-release tablets for attention deficit hyperactivity disorder (ADHD) reports having difficulty sleeping at night. Which assessment is most important for the nurse to obtain?

Which action should the nurse implement to assess the effectiveness of amlodipine?

Patient Data

History and Physical Notes

Flow Sheet

History and Physical

A 23-year-old female presents to the emergency department with altered mental status. She is accompanied by her roommate. The roommate says that symptoms started around 0900 today and have progressively worsened. She says the client first appeared euphoric but would switch to being irritable. The client also reported diarrhea and nausea. The client is combative. The client has a history of major depressive disorder and is being treated with paroxetine 50 mg PO once daily.

Nurse Notes

1830

The nurse notes significant diaphoresis. The client appears confused and disoriented to person, place, and time. Lung sounds are clear. No arrhythmia is noted. Palpated pulses are strong and bounding. Capillary refill is less than 3 seconds. Intermittent rigidity with myoclonus is noted in both upper extremities.

Flow Sheet

Day 1, 1830

Vital Signs

• Temperature 102°F (38.8°C)
• Heart rate 118 beats/minute
• Respirations 16 breaths/minute
• Blood pressure 168/94 mm Hg
• Oxygen saturation 97% on room air
• Height 5 feet, 4 inches (64 cm)
• Weight 136 pounds (61.6 kg)

Question:

Which assessment findings require follow-up by the nurse? Select all that apply.

The nurse is providing medication teaching to a client with bipolar disorder who receives a prescription for lithium carbonate. Which instruction should the nurse emphasize with the client?