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A nurse is assessing a client who is experiencing an anaphylactic reaction to an antibiotic. Which of the following manifestations of anaphylaxis should the nurse expect?
- A. Hypertonic reflexes
- B. Increase in systolic blood pressure
- C. Angioedema
- D. Urinary retention
Correct Answer: C
Rationale: The correct answer is C: Angioedema. Anaphylaxis is a severe allergic reaction that can cause swelling of the deep layers of the skin, including the subcutaneous tissue and mucosa. Angioedema is a common manifestation of anaphylaxis, typically involving swelling of the lips, face, and throat, which can lead to airway obstruction.
A: Hypertonic reflexes - This is not a typical manifestation of an anaphylactic reaction. Anaphylaxis is more commonly associated with hypotension.
B: Increase in systolic blood pressure - Anaphylaxis typically causes a rapid decrease in blood pressure, leading to hypotension rather than hypertension.
D: Urinary retention - This is not a common manifestation of an anaphylactic reaction. Anaphylaxis is more likely to cause symptoms such as urticaria, bronchospasm, and gastrointestinal symptoms.
Therefore, the correct answer is C, as angioed
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A nurse is reviewing the laboratory results of a client who has been taking warfarin for 3 months. Which of the following laboratory results Indicates that the medication has been effective?
- A. Hgb 14 g/dL
- B. WBC count 10,000/mm3
- C. INR 2.0
- D. Platelets 150,000/mm3
Correct Answer: C
Rationale: The correct answer is C: INR 2.0. INR (International Normalized Ratio) measures the effectiveness of warfarin in preventing blood clotting. A therapeutic range for INR in clients on warfarin is typically between 2.0 and 3.0. An INR of 2.0 indicates that the medication is within the desired range and is effectively anticoagulating the blood to prevent clot formation.
Choice A (Hgb 14 g/dL) is a normal hemoglobin level and does not directly reflect warfarin effectiveness. Choice B (WBC count 10,000/mm3) measures white blood cells and is not related to warfarin efficacy. Choice D (Platelets 150,000/mm3) is a normal platelet count and does not indicate the effectiveness of warfarin.
A nurse discovers that a client has been administered a higher dose of oxybutynin than the prescription indicates. The nurse should assess the client for which of the following adverse effects?
- A. Increased salivation
- B. Hyperthermia
- C. Urinary incontinence
- D. Bradycardia
Correct Answer: D
Rationale: Rationale for Correct Answer (D - Bradycardia): Excess oxybutynin can lead to anticholinergic effects, including decreased heart rate (bradycardia). This is due to the drug's action on muscarinic receptors in the heart. Assessing for bradycardia is crucial as it can indicate toxicity.
Summary of Incorrect Choices:
A: Increased salivation - Oxybutynin is an anticholinergic drug that typically causes dry mouth, not increased salivation.
B: Hyperthermia - Oxybutynin toxicity does not commonly lead to hyperthermia.
C: Urinary incontinence - Oxybutynin is used to treat urinary incontinence, so excess dose would not cause this adverse effect.
E, F, G: No further choices provided.
A nurse is providing teaching for a client who has a prescription for gentamicin. Which of the following should the nurse include as an adverse effect of this medication?
- A. Urinary frequency
- B. Constipation
- C. Hypertension
- D. Tinnitus
Correct Answer: D
Rationale: The correct answer is D: Tinnitus. Gentamicin is known to cause ototoxicity, including tinnitus, which is a ringing or buzzing sound in the ears. This adverse effect is important for the nurse to include in teaching to monitor for hearing changes. Urinary frequency (A), constipation (B), and hypertension (C) are not commonly associated with gentamicin use, so they are incorrect choices.
A nurse is caring for a client who is receiving neostigmine. Which of the following manifestations should the nurse identify as an adverse reaction to the medication?
- A. Hypoactive bowel sounds
- B. Sweating
- C. Respiratory distress
- D. Urinary retention
- E. Bradycardia
Correct Answer: B,C,E
Rationale: The correct manifestations for an adverse reaction to neostigmine are sweating, respiratory distress, and bradycardia. Neostigmine is a cholinesterase inhibitor, which can lead to overstimulation of the parasympathetic nervous system. Sweating is a common side effect due to increased cholinergic activity. Respiratory distress can occur due to bronchoconstriction from excessive cholinergic stimulation. Bradycardia can result from increased vagal tone. Hypoactive bowel sounds and urinary retention are not typically associated with neostigmine.
A nurse is caring for a client who is receiving meperidine. Which of the following is the nurse's priority assessment before administering the medication?
- A. Urinary retention
- B. Vomiting
- C. Respiratory rate
- D. Level of consciousness
Correct Answer: C
Rationale: The correct answer is C: Respiratory rate. Meperidine is an opioid analgesic that can cause respiratory depression. Therefore, assessing the client's respiratory rate before administering the medication is crucial to prevent potential respiratory compromise. This assessment helps the nurse ensure the client can safely tolerate the medication and intervene promptly if respiratory depression occurs.
Urinary retention (choice A) is a potential side effect of meperidine but is not the priority assessment compared to respiratory rate. Vomiting (choice B) may be a concern in terms of medication absorption but does not directly relate to the risk of respiratory depression. Level of consciousness (choice D) is important but may be influenced by respiratory status, making respiratory rate the priority assessment.