Nokea
For which of the following adverse effects should the nurse monitor a client who is prescribed metoclopramide following bowel surgery?
- A. Muscle weakness
- B. Sedation
- C. Tinnitus
- D. Peripheral edema
Correct Answer: B
Rationale: The correct answer is B: Sedation. Metoclopramide is a medication that can cause sedation as a side effect. After bowel surgery, sedation can mask signs of postoperative complications such as abdominal pain or changes in vital signs. Muscle weakness (A), tinnitus (C), and peripheral edema (D) are not common adverse effects of metoclopramide and would not typically be monitored for in this situation. Sedation is the most relevant adverse effect to monitor for in a client post-bowel surgery, as it can impact the assessment and management of their recovery.
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A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift and the client received atenolol instead of allopurinol. Which of the following actions should the nurse take first?
- A. Obtain the client's blood pressure
- B. Contact the client's provider
- C. Inform the charge nurse
- D. Complete an incident report
Correct Answer: A
Rationale: The correct answer is A: Obtain the client's blood pressure. The nurse's first priority is to assess the client's current condition and potential adverse effects of atenolol. Atenolol is a beta-blocker that can lower blood pressure and heart rate. Obtaining the client's blood pressure will help determine if any immediate interventions are needed. Contacting the provider (B) can be done after assessing the client's condition. Informing the charge nurse (C) is important but not the first priority. Completing an incident report (D) is necessary but should follow immediate client assessment. Other choices are not relevant to the immediate safety and well-being of the client.
A nurse is caring for a client who received 0.9% sodium chloride 1 L over 4 hr instead of over 8 hr as prescribeWhich of the following information should the nurse enter as a complete documentation of the incident?
- A. IV fluid infused over 4 hr instead of the prescribed 8 hr. Client tolerated fluids well, provider notified.
- B. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
- C. 1 L of 0.9% sodium chloride completed at 0900. Client denies shortness of breath.
- D. IV fluid initiated at 0500. Lungs clear to auscultation.
- E. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. This choice clearly states the key information - the type of IV fluid, volume, and duration of infusion.
2. Mentioning that vital signs were stable indicates client's safety was monitored.
3. Notifying the provider is crucial for any deviation from the prescribed treatment plan.
Incorrect Choices:
A. Fails to mention the type of IV fluid or client's vital signs, lacks detail.
C. Although it mentions the completion time, it does not address the deviation or client's tolerance.
D. Provides irrelevant information about the initiation time and lung assessment.
E. Similar to choice B, but lacks mentioning the infusion duration which is critical for documenting the incident.
Which of the following statements should the nurse include in the teaching about the new medication? Select the 2 statements the nurse should include in the teaching.
- A. You should take medication with dairy products
- B. This medication may cause constipation.
- C. It is common to experience headache or blurred vision while taking this medication.
- D. You should avoid the sun while taking this medication.
Correct Answer: B, D
Rationale: The correct answers are B and D. Statement B is important as it informs the patient about a potential side effect (constipation) of the medication, promoting awareness and preparedness. Statement D is crucial as some medications can increase sensitivity to sunlight, leading to adverse reactions like sunburn. Choices A, C, and the remaining options are incorrect as taking medication with dairy products can interfere with absorption, experiencing headache or blurred vision is not common for all medications, and not all medications require sun avoidance.
Which of the following actions of sucralfate should the nurse include in the teaching for a client who is to start a new prescription for sucralfate for peptic ulcer disease?
- A. Decreases stomach acid secretion
- B. Neutralizes acids in the stomach
- C. Forms a protective barrier over ulcers
- D. Treats ulcers by eradicating H. pylori
Correct Answer: C
Rationale: The correct answer is C: Forms a protective barrier over ulcers. Sucralfate works by forming a protective barrier over ulcers in the stomach and small intestine, providing a physical barrier to prevent further damage from stomach acid. This action helps promote healing of the ulcers. Choices A, B, and D are incorrect because sucralfate does not decrease stomach acid secretion, neutralize acids in the stomach, or treat ulcers by eradicating H. pylori bacteria. It is important for the nurse to educate the client on the mechanism of action of sucralfate to ensure understanding and adherence to the treatment plan.
Which of the following adverse effects should the nurse include in the teaching for a client who is to begin taking tamoxifen for the treatment of breast cancer?
- A. Urinary retention
- B. Constipation
- C. Bradycardia
- D. Hot flashes
Correct Answer: D
Rationale: The correct answer is D: Hot flashes. Tamoxifen is known to cause hot flashes as a common side effect due to its estrogen-blocking properties. This is important to include in teaching as it can affect the client's quality of life. Urinary retention (A), constipation (B), and bradycardia (C) are not commonly associated with tamoxifen use. Hot flashes are a well-documented side effect, making it the most appropriate choice for client education.