the nurse is caring for a client who is receiving intravenous vancomycin which assessment finding should the nurse report immediately
Logo

Nursing Elites

ATI LPN

Medical Surgical ATI Proctored Exam

1. The client is receiving intravenous vancomycin. Which assessment finding should the nurse report immediately?

Correct answer: A

Rationale: Red man syndrome is a severe and potentially life-threatening reaction to vancomycin characterized by flushing, rash, and hypotension. Immediate intervention is required to prevent further complications such as anaphylaxis. Therefore, the nurse should report this finding immediately to ensure prompt treatment and prevent serious adverse effects.

2. A client with a history of myocardial infarction (MI) is prescribed nitroglycerin (Nitrostat) for chest pain. Which instruction should the nurse provide?

Correct answer: D

Rationale: The correct instruction for a client prescribed nitroglycerin (Nitrostat) for chest pain is to place the tablet under the tongue. This route allows for rapid absorption of the medication, providing quick relief for chest pain associated with myocardial infarction.

3. A patient is being cared for after bariatric surgery, and the healthcare provider is assessing for hemorrhage. What is a sign of hemorrhage?

Correct answer: B

Rationale: Frank red bleeding from the surgical site is a significant sign of hemorrhage that warrants immediate attention. It indicates active bleeding that needs to be addressed promptly to prevent further complications.

4. Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy?

Correct answer: C

Rationale: Administering on-call sedation is crucial before a bronchoscopy to ensure the client is comfortable and adequately prepared for the procedure. Sedation helps reduce anxiety, discomfort, and ensures the client remains still during the bronchoscopy, enabling the healthcare provider to perform the procedure effectively.

5. A client is being discharged with a new prescription for enoxaparin (Lovenox). Which instruction should the nurse include?

Correct answer: B

Rationale: The correct instruction for a client with a prescription for enoxaparin (Lovenox) is not to expel the air bubble from the syringe before injection. This ensures the full dose is delivered without affecting the medication's efficacy. Expelling the air bubble may lead to a loss of medication, resulting in suboptimal treatment. Therefore, it is crucial for the client to follow this instruction to receive the intended therapeutic effect of enoxaparin.

Similar Questions

A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?
When assessing a client with a chest tube connected to suction, which observation indicates that the chest tube is functioning properly?
A patient with chronic kidney disease (CKD) is prescribed erythropoietin. What is the primary action of this medication?
A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms?
A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). Which laboratory value indicates a therapeutic effect of the medication?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses