a patient who is taking trimethoprim sulfamethoxazole tmp smx calls to report developing an all over rash the nurse will instruct the patient to perfo
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Nursing Elites

HESI RN

HESI Medical Surgical Assignment Exam

1. A patient who is taking trimethoprim-sulfamethoxazole (TMP-SMX) calls to report developing an all-over rash. What action should the nurse instruct the patient to perform?

Correct answer: C

Rationale: When a patient develops an all-over rash while taking trimethoprim-sulfamethoxazole (TMP-SMX), it may indicate a serious drug reaction. In this case, the patient should stop taking the medication immediately and notify their healthcare provider. Increasing fluid intake (Choice A) may be beneficial in some cases but is not the priority when a serious drug reaction is suspected. Taking diphenhydramine (Choice B) may help with itching but does not address the underlying issue of a potential drug reaction. Continuing the medication (Choice D) is not advisable when a serious adverse reaction such as a widespread rash occurs.

2. A client taking furosemide (Lasix) reports difficulty sleeping. What question is important for the nurse to ask the client?

Correct answer: D

Rationale: The nurse needs to determine at what time of day the client takes the Lasix. Due to the diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia, which may be contributing to the sleep difficulties. Asking about the dose of medication (Choice A) is important but addressing the timing of intake is more crucial in this situation. Inquiring about potassium-rich foods (Choice B) is relevant for clients on potassium-sparing diuretics. Weight loss (Choice C) may be relevant for monitoring the client's overall health but is not directly related to the sleep issue in this case.

3. The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which symptoms should the nurse tell the client to report to the healthcare provider?

Correct answer: A

Rationale: Rapid weight gain can indicate fluid retention, which is a serious side effect of prednisone and should be reported.

4. Which of the following is a primary intervention for a patient with sepsis?

Correct answer: D

Rationale: Monitoring blood cultures is a primary intervention for a patient with sepsis because it helps identify the causative organism, which is crucial in guiding appropriate antibiotic therapy. Administering antibiotics (Choice A) is important in treating sepsis but is considered a secondary intervention. Administering IV fluids (Choice B) is also crucial for sepsis management to restore perfusion and hemodynamic stability. Administering antipyretics (Choice C) may help reduce fever, but it is not a primary intervention for managing sepsis.

5. What is the priority intervention for a patient with a suspected myocardial infarction (MI)?

Correct answer: A

Rationale: Administering oxygen is the priority intervention for a patient with a suspected myocardial infarction to improve oxygenation. Oxygen helps ensure an adequate oxygen supply to the heart muscle, reducing the workload on the heart. Nitroglycerin and aspirin are important interventions in the treatment of MI; however, oxygen administration takes precedence to ensure adequate oxygenation. Morphine may be considered for pain relief, but it is not the initial priority in the treatment of a suspected MI.

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