A client is using omalizumab (Xolair) for the first time. What is the priority nursing action?
a. Make sure the client takes the medication with water.
b. Administer ibuprofen (Motrin) because Xolair often causes headaches.
c. Teach the client how to use a syringe.
d. Remain with the client and assess for anaphylaxis.
D
Immune modulators are monoclonal antibodies that prevent allergens from binding to receptor sites on mast cells and basophils. The risk of anaphylaxis is high; the nurse should assess and stay with the client.
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A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding,
as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: a. Aphthous ulcers. b. Candidiasis. c. Leukoplakia. d. Koplik spots.
A client is found to be comatose and hypoglycemic with a blood sugar of 50 mg/dL. Which of the following nursing actions should be implemented first?
A) Infuse 1000 mL D5W over a 12-hour period. B) Administer 50% glucose intravenously. C) Check the client's urine for the presence of sugar and acetone. D) Encourage the client to drink orange juice with added sugar.
The nurse is providing holistic client care. This means the:
a. client's physical status is addressed. b. client's sociocultural status is addressed. c. client receives cost-effective care. d. mind, body, and spirit of the client are addressed.
Which safety measure should the nurse use for a client who has adrenocortical insufficiency?
A. Pad the siderails of the client's bed. B. Assist the client to change positions slowly. C. Use a lift sheet to change the client's position. D. Keep suctioning equipment at the client's bedside.