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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 receiving a prescription for sucralfate to treat a peptic ulcer. Which instruction should the nurse provide during discharge education?

A client who is taking furosemide reports experiencing leg cramps, a cough, feeling tired, and palpitations. Which action should the nurse take first?

A client who received a renal transplant three months ago is readmitted to the acute care unit with signs of graft rejection. While taking the client’s history, the nurse determines that the client has been self-administering St. John’s Wort, an herbal preparation, on the advice of a friend. Which information is most significant about this finding?

The nurse observes that a client has become lethargic 30 minutes after receiving an opioid injection for pain. Which vital sign should the nurse obtain first?

A client receives a prescription for allopurinol. Which information provided by the client requires additional instruction by the nurse?

A client with peptic ulcer disease receives a new prescription for cimetidine. Which statement provided by the client requires additional instruction by the nurse?

A client with chemotherapy-induced nausea receives a prescription for metoclopramide. Which adverse effect is most important for the nurse to report?

A client with nasal congestion receives a prescription for phenylephrine 10 mg PO every 4 hours. Which client condition should the nurse report to the healthcare provider before administering the medication?

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:

A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client and family that glucagon needs to be administered?