Nokea
A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
- A. Weight gain
- B. Hair loss
- C. Sore throat
- D. Brittle nails
Correct Answer: C
Rationale: Pulmozyme, used to thin mucus in cystic fibrosis, can cause sore throat as a side effect due to irritation from inhalation.
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The nurse is preparing to teach a client about phenytoin sodium (Dilantin). Which fact would be most important to teach the client regarding why the drug should not be stopped suddenly?
- A. Physical dependence can develop over time.
- B. Status epilepticus can develop.
- C. A hypoglycemic reaction can develop.
- D. Heart block can develop.
Correct Answer: B
Rationale: Abruptly stopping phenytoin can precipitate status epilepticus, a life-threatening condition, due to loss of seizure control.
The nurse has just returned to the desk and has four phone messages to return. Which of the following messages should the nurse return FIRST?
- A. A woman in her first trimester of pregnancy complaining of heartburn.
- B. A man complaining of heartburn that radiates to his jaw.
- C. A woman complaining of hot flashes and difficulty sleeping.
- D. A boy complaining of knee pain after playing basketball.
Correct Answer: B
Rationale: indicates chest pain, needs to seek medical attention immediately
A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system:
- A. Can be disconnected from suction if the chest tube is clamped
- B. Can be disconnected from suction, but the chest tube should remain unclamped
- C. Must remain connected by means of a portable suction
- D. Must be kept even with the client's shoulders during the transport
Correct Answer: B
Rationale: The chest tube should remain unclamped and disconnected from suction during transport to prevent tension pneumothorax, with the system kept below chest level.
When determining whether or not a client is a candidate for restraints, which of the following would be considered an appropriate reason for a restraint?
- A. Current dangerous behavior
- B. History of falls
- C. Recent violent attack on a staff member
- D. Refusal to cooperate with treatment
Correct Answer: A
Rationale: Restraints are justified for current dangerous behavior (A) posing immediate risk to self or others. History of falls (B), past violence (C), or non-cooperation (D) do not warrant restraints.
A child with thrush has been prescribed fluconazole (Diflucan). The child's mother asks what this medication is used for, and the nurse correctly replies,
- A. This is an antiviral medication used to treat your child's viral infection.'
- B. This medication is used to treat yeast infections.'
- C. This medication is an analgesic that will ease your child's pain while eating.'
- D. This is an antibiotic for your child's bacterial infection.'
Correct Answer: B
Rationale: Fluconazole is an antifungal used to treat thrush, a yeast infection caused by Candida.