Author Question: While assessing a client, the nurse observes hives and flushing. The client reports itching and a ... (Read 42 times)

bcretired · **on:** Jul 23, 2018

While assessing a client, the nurse observes hives and flushing. The client reports itching and a tightness in the throat. The nurse would identify which of the following nursing diagnoses?

A) Risk for Allergy Response
B) Ineffective Tissue Perfusion
C) Decreased Cardiac Output
D) Risk for Injury

Question 2

A client is prescribed norepinephrine IV. Which of the following would be appropriate for the nurse to do? Select all that apply.

A) Administer the drug via a gravity infusion.
B) Dilute the drug with sterile saline.
C) Continuously monitor the client's blood pressure.
D) Check the IV insertion site for leakage.
E) Assess the client's urinary output hourly.

parker125 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: A
Feedback:
The client is exhibiting signs and symptoms of an allergic reaction. Therefore, Risk for Allergy Response would be appropriate. Ineffective Tissue Perfusion and Decreased Cardiac Output would be appropriate if a client is experiencing hypotension and shock. Risk for Injury would be appropriate if the client was experiencing dizziness, weakness, confusion, or disorientation related to the drug therapy.

Answer to Question 2

Ans: C, D, E
Feedback:
When giving norepinephrine IV, the nurse should use an electronic infusion pump, not dilute the norepinephrine solution, continuously monitor the client's blood pressure, check the IV site for leakage or extravasation, restart the IV in another location if extravasation occurs and institute extravasation protocol according to the facility's policy, and assess the client's urine output hourly.