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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 administers risedronate to a client with osteoporosis at 0700. The client asks for a glass of milk to drink with the medication. Which action should the nurse take?

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

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 client who is newly diagnosed with diabetes insipidus (DI) is receiving synthetic vasopressin intravenously. Which side effect of vasopressin reported by the client should the nurse report to the healthcare provider?

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?

After receiving the third dose of a new oral anticoagulant prescription, an older adult client develops bleeding and tender gums and has many new bruises. Which actions should the nurse implement? Select all that apply.

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.

A client with benign prostatic hyperplasia receives a new prescription of tamsulosin. Which intervention should the nurse perform to monitor for an adverse reaction?

A client has a new prescription for diclofenac, a nonsteroidal anti-inflammatory drug (NSAID). Which information in the client’s history is of greatest concern to the nurse in monitoring the client’s response to this medication?

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?