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A client admitted to the hospital has been prescribed pyridostigmine. When assessing the client for side effects of the medication, the nurse should ask the client about the presence of which occurrence?
- A. Mouth ulcers
- B. Muscle cramps
- C. Feelings of depression
- D. Unexplained weight gain
Correct Answer: B
Rationale: Pyridostigmine is an acetylcholinesterase inhibitor used to treat myasthenia gravis, a neuromuscular disorder. Muscle cramps and small muscle contractions are side effects and occur as a result of overstimulation of neuromuscular receptors. Mouth ulcers, depression, and weight gain are not associated with this medication.
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The nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse should instruct mothers to take which action?
- A. If antibiotic ointment has been applied to the cord, it is not necessary to do anything else to it.
- B. All that is necessary is to wash the cord with antibacterial soap and allow it to air-dry once a day.
- C. Apply alcohol thoroughly to the cord, being careful not to move the cord because it will cause pain to the newborn infant.
- D. Apply the prescribed cleansing agent to the cord, ensuring that all areas around the cord are cleaned two to three times a day.
Correct Answer: D
Rationale: The cord and base should be cleansed with alcohol (or another substance as prescribed) thoroughly, two to three times per day. The steps are (1) lift the cord; (2) wipe around the cord, starting at the top; (3) clean the base of the cord; and (4) fold the diaper below the umbilical cord to allow the cord to air-dry and prevent contamination from urine. Antibiotic ointment is not normally prescribed. Continuation of cord care is necessary until the cord falls off within 7 to 14 days. Water and soap are not necessary; in fact, the cord should be kept from getting wet. The infant does not feel pain in this area.
The nurse evaluates a client after treatment for carbon monoxide poisoning following a burn injury. The nurse should document that the treatment was effective if which finding was present? Select all that apply.
- A. The client is sleeping soundly.
- B. The client is awake and talking.
- C. Respiratory rate is 26 breaths/minute.
- D. The client's heart rate is 84 beats/minute.
- E. Carboxyhemoglobin levels are less than 5%.
- F. The heart monitor shows normal sinus rhythm.
Correct Answer: D,E,F
Rationale: Normal carboxyhemoglobin levels are less than 5% for a nonsmoking adult. Clients can be awake and talking with abnormally high levels. The symptoms of carbon monoxide poisoning are tachycardia, tachypnea, and central nervous system depression.
The emergency department nurse is assessing a client who abruptly discontinued benzodiazepine therapy and is experiencing withdrawal. Which manifestations of withdrawal should the nurse expect to note? Select all that apply.
- A. Tremors
- B. Sweating
- C. Lethargy
- D. Agitation
- E. Nervousness
- F. Muscle weakness
Correct Answer: A,B,D,E
Rationale: Benzodiazepines should not be abruptly discontinued because withdrawal symptoms are likely to occur. Withdrawal symptoms include tremor, sweating, agitation, nervousness, insomnia, anorexia, and muscular cramps. Withdrawal symptoms from long-term, high-dose benzodiazepine therapy include paranoia, delirium, panic, hypertension, and status epilepticus. Lethargy is not associated with benzodiazepine withdrawal.
The nurse should place a client who sustained a head injury in which position to prevent increased intracranial pressure (ICP)?
- A. In left Sims' position
- B. In reverse Trendelenburg
- C. With the head elevated on a small, flat pillow
- D. With the head of the bed elevated at least 30 degrees
Correct Answer: D
Rationale: The client with a head injury is positioned to avoid extreme flexion or extension of the neck and to maintain the head in the midline, neutral position. The head of the bed is elevated to at least 30 degrees or as recommended by the primary health care provider. The client is log rolled when turned to avoid extreme hip flexion.
The nurse reviews the results of a blood chemistry profile for a client who is experiencing late-stage salicylate poisoning and metabolic acidosis. Which serum study should the nurse review for data about the client's acid-base balance?
- A. Sodium
- B. Potassium
- C. Magnesium
- D. Phosphorus
Correct Answer: B
Rationale: A client with late-stage salicylate poisoning is at risk for metabolic acidosis because acetylsalicylic acid increases the client's hydrogen ion (H+) concentration, decreases the pH, and creates a bicarbonate deficit. Hyperkalemia develops as the body attempts to compensate for the influx of H+ by moving H+ into the cell and potassium out of the cell; thus, potassium accumulates in the extracellular space. Clinical manifestations of metabolic acidosis include the clinical indicators of hyperkalemia, including hyperpnea, central nervous system depression, twitching, and seizures. Options 1, 3, and 4 are not primary concerns.