Nokea
A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following should the nurse identify as an adverse effect of this medication?
- A. Hypoglycemia
- B. Bradycardia
- C. Red man syndrome
- D. Hypotension
Correct Answer: D
Rationale: The correct answer is D: Hypotension. Phenytoin can cause hypotension as an adverse effect due to its vasodilatory properties. The drug can cause a decrease in blood pressure, leading to symptoms such as dizziness and lightheadedness. This adverse effect is important for the nurse to recognize as it can potentially lead to complications such as falls in the client.
A: Hypoglycemia is not a common adverse effect of phenytoin.
B: Bradycardia is not a typical adverse effect of phenytoin.
C: Red man syndrome is associated with vancomycin, not phenytoin.
Summary: Phenytoin is more likely to cause hypotension as an adverse effect, rather than hypoglycemia, bradycardia, or red man syndrome.
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A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol, characterized by symptoms similar to Parkinson's disease. A shuffling gait, which is a slow, dragging walk with short steps and reduced arm swing, is a classic manifestation. Serpentine limb movement (A) is not associated with pseudoparkinsonism. Nonreactive pupils (C) are not a typical symptom of pseudoparkinsonism. Smacking lips (D) is a sign of tardive dyskinesia, another side effect of antipsychotic medications.
A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?
- A. Apply firm pressure to the injection site following administration
- B. Administer the medication into the client's muscle
- C. Expel the air bubble from the syringe prior to injection
- D. Insert the syringe needle halfway into the client's skin
Correct Answer: A
Rationale: Correct Answer: A: Apply firm pressure to the injection site following administration.
Rationale: Applying firm pressure to the injection site following administration of enoxaparin helps minimize the risk of bleeding, as enoxaparin is an anticoagulant medication. This pressure promotes clot formation and reduces the likelihood of bruising or hematoma formation at the injection site.
Summary of other choices:
B: Administer the medication into the client's muscle - Incorrect. Enoxaparin is a subcutaneous medication, not meant for intramuscular administration.
C: Expel the air bubble from the syringe prior to injection - Good practice but not directly related to the administration of enoxaparin.
D: Insert the syringe needle halfway into the client's skin - Incorrect. The needle should be fully inserted for proper subcutaneous injection.
A nurse is instructing a client who has a new prescription for a daily dose of lovastatin extended-release. Which of the following information should the nurse include in the teaching?
- A. You will need liver function tests before beginning therapy.
- B. Avoid consuming dairy products while taking this medication.
- C. You may crush the medication and mix it with applesauce.
- D. You should take the medication in the morning.
Correct Answer: A
Rationale: The correct answer is A: You will need liver function tests before beginning therapy. This is important because lovastatin, a statin medication, can potentially cause liver damage. Liver function tests are necessary to monitor for any signs of liver toxicity. Choice B is incorrect because there is no specific interaction between lovastatin and dairy products. Choice C is incorrect as lovastatin extended-release should not be crushed as it may affect its effectiveness. Choice D is incorrect as there is no specific time of the day required to take lovastatin.
A nurse is assessing a client following the administration of ondansetron (Zofran). Which of the following findings should indicate to the nurse that the ondansetron has been effective?
- A. Client reports a decrease in pain
- B. Client reports a decrease in nausea
- C. Client reports a decrease in coughing
- D. Client reports a decrease in diarrhea
Correct Answer: B
Rationale: The correct answer is B: Client reports a decrease in nausea. Ondansetron is primarily used to treat nausea and vomiting. If the client reports a decrease in nausea, it indicates that the medication has been effective in managing this specific symptom. Decrease in pain (choice A) is not directly related to the action of ondansetron. Choices C (decrease in coughing) and D (decrease in diarrhea) are not typical indications of ondansetron's effectiveness. It is important for the nurse to focus on the specific expected outcome of the medication, which is the reduction of nausea and vomiting.
A nurse is preparing to initiate IV therapy for a client. Which of the following sites should the nurse use to place the peripheral IV catheter?
- A. Nondominant dorsal venous arch
- B. Dominant distal dorsal vein
- C. Nondominant forearm basilic vein
- D. Dominant antecubital vein
Correct Answer: A
Rationale: The correct answer is A: Nondominant dorsal venous arch. This site is preferred for peripheral IV catheter placement due to the larger vein diameter, ease of access, and reduced risk of complications like nerve damage or infiltration. The nondominant side is chosen to prevent disruption of daily activities. The dorsal venous arch is a superficial vein that is easily visible and palpable, making it suitable for successful cannulation. It also allows for optimal flow rate and minimizes the risk of phlebitis. Choices B, C, and D are not ideal for various reasons such as smaller vein size, increased risk of nerve damage, and difficulty in accessing or securing the catheter.