Nokea
A client with suspected vitamin C toxicity presents to the ED. Which manifestations of toxicity would the nurse expect in this client? Select all that apply.
- A. muscle weakness
- B. halos around objects
- C. occult rectal bleeding
- D. dry mucous membranes
- E. increased estrogen levels
Correct Answer: C
Rationale: Vitamin C toxicity can cause gastrointestinal irritation, leading to occult rectal bleeding. Other options are not associated with vitamin C toxicity.
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The nurse is caring for a client receiving total parenteral nutrition (TPN). During the assessment, the nurse notes absence of breath sounds on the right side, where the central catheter is placed. Which of the following does the nurse suspect is responsible for this abnormal assessment finding?
- A. air embolism
- B. fluid overload
- C. pneumothorax
- D. refeeding syndrome
Correct Answer: C
Rationale: Absent breath sounds on the side of a central catheter suggest pneumothorax, a potential complication of catheter insertion. Air embolism (A) causes cardiovascular symptoms, fluid overload (B) causes bilateral lung issues, and refeeding syndrome (D) affects electrolytes.
The nurse is caring for a client scheduled to receive cyclopentolate HCl preoperatively. Which finding in the client's history would prompt the nurse to notify the health care provider?
- A. osteoporosis
- B. hypothyroidism
- C. renal insufficiency
- D. cardiac dysrhythmias
Correct Answer: D
Rationale: Cyclopentolate, a mydriatic, has anticholinergic effects that can exacerbate cardiac dysrhythmias by increasing heart rate, necessitating provider notification.
The nurse is caring for a client with a staph infection. The client has orders for vancomycin 15 mg/kg per 12 hours. The client weighs 136 pounds. How much of this medication will the client receive every 12 hours?
Correct Answer: 930 mg
Rationale: Convert 136 pounds to kilograms (136 ÷ 2.2 = 61.82 kg). Calculate dose: 15 mg/kg X 61.82 kg = 927.3 mg, rounded to 930 mg every 12 hours.
An adolescent client ingests a large number of acetaminophen tablets in an attempt to commit suicide. Which laboratory result is associated with acetaminophen overdose?
- A. metabolic alkalosis
- B. increased blood urea nitrogen level
- C. decreased hemoglobin and hematocrit
- D. elevated liver enzyme levels
Correct Answer: D
Rationale: Acetaminophen overdose causes hepatotoxicity, leading to elevated liver enzyme levels (e.g., AST, ALT).