A nurse is caring for a client who has been administered penicillin. The nurse observes
that the client is exhibiting difficulty in breathing and is developing syncopal episodes.
On examining the client's vital signs, the nurse notes rapid pulse and palpitations. What
may this indicate?
A) Medication toxicity
B) Paradoxical effect
C) Therapeutic effect
D) Anaphylactic reaction
D
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A client asks the nurse to explain the importance of T-cell lymphocytes. In discussing the various types of T cells, the nurse would explain that suppressor T cells do which of the following things?
1. Recognize foreign antigens and initiate a quick response 2. Weaken certain foreign proteins so other cells can kill them easier 3. Turn off immune response to protect body from self-destruction 4. Keep opportunistic diseases from developing and/or worsening
Ellen is a novice nurse on your unit. Even though she has come to you highly recommended, as her supervisor, you have noticed some knowledge and skill deficiencies
These deficiencies have been noticed by her peers as well, who cover for her because she is new and they like her. Which of the following is likely to be the greatest asset to Ellen in improving her performance? a. Ignore Ellen's errors until she has more experience. b. Instruct staff to avoid working with Ellen until she learns to how do things herself. c. Ask Ellen to complete a self-assessment, using a standard skills checklist. d. Encourage staff to report every behavior of Ellen's that is different from theirs.
The nurse plans a therapeutic diet for a client with congestive heart failure. Which should the nurse include in the client's diet to facilitate excretion of fluid?
1. Fresh fruit 2. Daily fiber 3. Egg whites 4. Lean protein
A client complains of a headache and chills during a blood transfusion. Which one of the following actions should the nurse take immediately?
a. Check the vital signs. b. Stop the blood transfusion. c. Slow the rate of blood flow. d. Notify the physician and blood bank personnel.