Nokea
Which of the following findings should the nurse report to the provider as an adverse effect of gentamicin?
- A. Constipation
- B. Tinnitus
- C. Hypoglycemia
- D. Joint pain
Correct Answer: B
Rationale: The correct answer is B: Tinnitus. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, including tinnitus. Tinnitus is characterized by ringing or buzzing in the ears and can be an early sign of auditory nerve damage. This adverse effect should be reported to the provider promptly to prevent further hearing loss.
A: Constipation is not a typical adverse effect of gentamicin.
C: Hypoglycemia is not a known adverse effect of gentamicin.
D: Joint pain is not commonly associated with gentamicin use.
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Which of the following medications should the nurse plan to administer to a client with myasthenia gravis who is in a cholinergic crisis?
- A. Potassium Iodide
- B. Glucagon
- C. Atropine
- D. Protamine
Correct Answer: C
Rationale: Rationale:
C: Atropine is the correct answer because it is an anticholinergic medication that can counteract the excess acetylcholine causing cholinergic crisis in myasthenia gravis.
Incorrect choices:
A: Potassium Iodide is used for thyroid conditions, not for myasthenia gravis crises.
B: Glucagon is used for hypoglycemia, not for myasthenia gravis crises.
D: Protamine is used to reverse the effects of heparin, not for myasthenia gravis crises.
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client. Nursing Action: Document the blood product transfusion in the client's medical record.
- A. Indicated
- B. Not indicated
Correct Answer: A
Rationale: The correct answer is A: Indicated. Documenting the blood product transfusion in the client's medical record is crucial for legal, ethical, and continuity of care reasons. Documentation ensures that all relevant information about the transfusion is recorded accurately, including the type of blood product, volume infused, patient's vital signs, any adverse reactions, and the healthcare provider's orders. This documentation serves as a permanent record of the procedure, aiding in monitoring the patient's response to the transfusion and facilitating communication among healthcare team members. Failure to document the blood transfusion can lead to serious consequences, such as improper monitoring, increased risk of errors, and compromised patient safety. Therefore, documenting the blood product transfusion in the client's medical record is a vital and necessary nursing action. Other choices are incorrect as they do not address the importance of documentation in ensuring safe and effective patient care.
A nurse is teaching a client about the prescribed medication. Which of the following statements should the nurse include when teaching the client about the prescribed medication? Select all that apply.
- A. The medication can cause nausea
- B. so take with a meal.
- C. You can experience vivid nightmares.
- D. You may notice your urine becomes lighter in color.
- E. Consumption of a high-protein meal can reduce the effectiveness of the medication.
- F. You may initially notice an increase in involuntary movements.
- G. This medication can make you light-headed if you stand up too quickly from a seated or lying position.
Correct Answer: A, B, E,F
Rationale: The correct statements to include when teaching the client about the prescribed medication are A, B, E, and F. Statement A is important to mention as it informs the client about a potential side effect (nausea) of the medication. Statement B is crucial as taking the medication with a meal can help reduce the likelihood of nausea occurring. Statement E is relevant because high-protein meals can indeed interfere with the medication's effectiveness, so the client should be aware of this. Statement F is crucial as it prepares the client for a possible side effect of an increase in involuntary movements. These statements are important for the client to understand to ensure safe and effective medication use. Statements C, D, and G are incorrect as they do not pertain to the medication's side effects, interactions, or administration, making them irrelevant in this context.
Which of the following actions is the priority for the nurse to take after inadvertently administering 160 mg of valsartan PO to a client who was scheduled to receive 80 mg?
- A. Evaluate the client for orthostatic hypotension
- B. Monitor the client's urine output
- C. Obtain the client's laboratory results
- D. Check the client for nasal congestion
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client for orthostatic hypotension. After administering a double dose of Valsartan, the priority is to assess the client for potential adverse effects such as a sudden drop in blood pressure, which can lead to orthostatic hypotension. This is crucial to prevent any harm to the client. Monitoring urine output (B) may be important but is not the immediate priority. Obtaining laboratory results (C) would not provide immediate information on the client's current condition. Checking for nasal congestion (D) is irrelevant to the situation.
Which of the following medications should the nurse anticipate administering to a client who has taken a large amount of diazepam?
- A. Ondansetron
- B. Magnesium Sulphate
- C. Flumazenil
- D. Protamine Sulphate
Correct Answer: C
Rationale: The correct answer is C: Flumazenil. Flumazenil is a benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose, such as diazepam. It competes with benzodiazepines at the receptor site, reversing their sedative and hypnotic effects. Ondansetron (A) is an antiemetic, Magnesium Sulphate (B) is used for various conditions like pre-eclampsia, Protamine Sulphate (D) is used to reverse heparin anticoagulation. Flumazenil is the most appropriate choice for reversing the effects of diazepam overdose.