Free Quiz

Rationale:

A. Encourage complete smoking cessation – Smoking is the primary risk factor and the most critical intervention in halting progression of Buerger’s disease. Even minimal tobacco use can worsen the condition.

B. Administer low-dose aspirin as prescribed – Aspirin can help reduce clot formation and improve blood flow in small vessels. It is often part of conservative therapy.

Rationale:

• B. Potassium (K⁺) –
  Amphotericin B is highly nephrotoxic and commonly causes renal impairment, which leads to potassium wasting and hypokalemia. Severe hypokalemia can result in cardiac arrhythmias, muscle weakness, and even paralysis.
  ➤ Because of this, serum potassium is the most critical lab to monitor closely during treatment.
• A. Hemoglobin (Hgb) –
  While anemia can occur with Amphotericin B over long-term use, it is not as immediately life-threatening or common as electrolyte imbalance.
• C. White blood cell count (WBC) –
  Monitoring infection is important, but WBC levels are not directly affected by Amphotericin B and do not guide its toxicity.
• D. ALT (Liver enzyme) –
  Amphotericin B is primarily nephrotoxic, not hepatotoxic. ALT is more relevant for drugs that affect the liver, such as isoniazid or acetaminophen.

Nursing Tip:

Other key monitoring during Amphotericin B therapy:

• Creatinine/BUN – due to nephrotoxicity
• Magnesium – hypomagnesemia may also occur
• Infusion reactions – fever, chills, hypotension
• Premedication with antipyretics or antihistamines is often required

Rationale:

• B. Notify the healthcare provider immediately –
  Sudden drooping of one eyelid (ptosis) may indicate a new neurological event, such as a stroke, cranial nerve III palsy, or Horner's syndrome. This is an unexpected neurological change that must be reported immediately.
  ➤ Prompt action is crucial to prevent progression or delay in diagnosis of a serious condition.
• A. Continue to monitor –
  This delays care. New neurological findings should never be ignored or simply monitored without informing the provider.
• C. Document and recheck in 2 hours –
  Documentation is important, but waiting 2 hours without notifying the provider could cause harm if this is the sign of a stroke or nerve damage.
• D. Elevate the head of bed and reassess in 30 min –
  There's no evidence this is related to position. It is a neurological symptom, not a postural issue, and needs immediate evaluation.

NCLEX Key Concept:

Any sudden change in neurological status — especially asymmetrical signs like drooping of one eyelid or facial asymmetry — must be treated as a potential emergency.

Rationale:

• A. Tacrolimus –
  A calcineurin inhibitor that suppresses T-cell activation, widely used to prevent rejection.
• B. Cyclosporine –
  Another calcineurin inhibitor with similar action but slightly different side effect profile.
• C. Mycophenolate mofetil –
  An antimetabolite that inhibits lymphocyte proliferation and is commonly prescribed as part of the immunosuppressive regimen.
• D. Prednisone –
  A corticosteroid used to reduce inflammation and suppress the immune response, usually part of combination therapy.
• E. Metformin –
  Used to manage type 2 diabetes, not related to transplant immunosuppression.
• F. Furosemide –

Rationale:

• D. Continue to monitor the client’s heart rhythm closely –
  Adenosine can cause a brief period of asystole or bradycardia immediately after administration. This is typically transient and lasts only a few seconds before normal sinus rhythm resumes. The nurse should monitor closely but not initiate CPR unless the asystole persists or the client shows signs of poor perfusion or deterioration.
• A. Initiate CPR immediately –
  Immediate CPR is not indicated for a brief, expected period of asystole caused by adenosine.
• B. Call the healthcare provider after 5 minutes –
  Immediate action depends on the client’s condition, not a timed delay.
• C. Prepare for synchronized cardioversion –
  Cardioversion is used for unstable tachyarrhythmias, not for brief asystole induced by adenosine.

Nursing Tip:

Adenosine is a short-acting AV node blocker used to terminate PSVT by temporarily blocking conduction. Brief asystole is a common expected effect. The nurse should have emergency equipment ready but remain calm and observant.

Rationale:

The clinical scenario describes a client with a recent cervical spinal cord injury showing signs of a potentially life-threatening complication known as autonomic dysreflexia. This medical emergency occurs most commonly in spinal injuries above the T6 level and is characterized by:

• Severe hypertension (BP: 190/70 mmHg)

• Reflex bradycardia (HR: 45 bpm)

• Altered mental status (difficult to arouse)

• Irregular, shallow respirations (possible neurological respiratory compromise)

Analysis of the Options:

A. Notify the healthcare provider immediately  (Correct)
This is the priority action because the client's vital signs and symptoms indicate a neurological emergency. Immediate notification allows the provider to initiate interventions such as IV antihypertensives or treatment of triggering causes (e.g., bladder distension, fecal impaction). Prompt communication is crucial to prevent seizures, stroke, or even death.

B. Administer atropine to increase heart rate 
While bradycardia is concerning, atropine should not be given automatically without first identifying the underlying cause or receiving an order from the provider. The nurse must notify the provider first.

C. Prepare for intubation 
Although the client's breathing is irregular and shallow, it may be related to autonomic dysreflexia and could improve with appropriate treatment. Preparing for intubation is not the first intervention without further assessment.

D. Elevate the head of the bed to 90 degrees 
This is a recommended intervention for autonomic dysreflexia, as it helps lower blood pressure. However, it does not replace the critical action of notifying the healthcare provider, which must occur first to guide proper treatment.