816） A client with depression receiving phenelzine sulfate (Nardil) suddenly complains of a severe headache and neck stiffness and soreness, and then begins to vomit. The nurse takes the client's blood pressure and notes that it is 210/102 mm Hg. On the basis of the findings, the nurse should obtain which medication from the emergency drawer of the medication cart?
Answer: 1. The antidote for hypertensive crisis is phentolamine. Hypertensive crisis may be manifested by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia or bradycardia and constricting chest pain also may be present.
817） The nurse is performing an assessment on a client who has returned from the postanesthesia care unit after a cystoscopy. Which assessment finding indicates a need to notify the health care provider (HCP)?
1.A temperature of 99.4° F
2.Grossly bloody urine with clots
3.A bluish or green tinge to the urine
4.A blood pressure of 120/82 mm Hg
Answer: 2. Grossly bloody urine with clots following cystoscopy is always an abnormal finding and should be reported to the HCP immediately. The client may have clear or blood-tinged urine after cystoscopy. If a contrast agent such as methylene blue is used, the urine may have an unusual bluish or green tinge. A blood pressure of 120/82 mm Hg and a temperature of 99.4° F are not abnormal findings at this time.
818） The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?
1.A clotting time of 10 minutes
2.An ammonia level of 20 mcg/dL
3.A platelet count of 50,000 cells/mm3
4.A white blood cell count of 5000 cells/mm3
Answer:3. Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000 cells/mm3. When the platelet count decreases, the client is at risk for bleeding. The normal white blood cell count is 4500 to 11,000 cells/mm3. When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/dL.