Nokea
A nurse is assessing a client after administering a second dose of cefazolin IV. The nurse notes the client has anxiety, hypotension, and dyspneWhich of the following medications should the nurse administer first?
- A. Diphenhydramine
- B. Albuterol inhaler
- C. Epinephrine
- D. Prednisone
Correct Answer: C
Rationale: The correct answer is C: Epinephrine. When a client exhibits symptoms of anxiety, hypotension, and dyspnea after receiving cefazolin IV, it indicates a severe allergic reaction/anaphylaxis. Epinephrine is the first-line medication for anaphylaxis as it acts quickly to reverse the symptoms by constricting blood vessels, increasing blood pressure, and opening airways. Diphenhydramine (A) is an antihistamine that can be given as a second-line treatment. Albuterol inhaler (B) is used for bronchospasm but is not the first choice in anaphylaxis. Prednisone (D) is a corticosteroid that may be used later for inflammation but is not the initial treatment for anaphylaxis.
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Which of the following medications should the nurse plan to administer to a client who has heroin toxicity, is unresponsive, has pinpoint pupils, and a respiratory rate of 8/min?
- A. Methadone
- B. Naloxone
- C. Diazepam
- D. Bupropion
Correct Answer: B
Rationale: The correct answer is B: Naloxone. Naloxone is an opioid antagonist that reverses the effects of opioids like heroin. In this scenario, the client's symptoms of unresponsiveness, pinpoint pupils, and respiratory depression indicate opioid toxicity. Naloxone will competitively bind to opioid receptors, reversing respiratory depression and potentially restoring consciousness. Methadone (A) is used for opioid dependence but not acute toxicity. Diazepam (C) is a benzodiazepine and not indicated for opioid toxicity. Bupropion (D) is an antidepressant and not appropriate for this situation.
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.
Which of the following findings should indicate to the nurse that a client with myasthenia gravis taking neostigmine is experiencing an adverse effect?
- A. Tachycardia
- B. Oliguria
- C. Xerostomia
- D. Miosis
Correct Answer: D
Rationale: The correct answer is D: Miosis. Neostigmine is a cholinesterase inhibitor used to treat myasthenia gravis. Miosis, or excessive constriction of the pupil, is a sign of cholinergic crisis which can occur due to neostigmine overdose. This adverse effect indicates excessive stimulation of the parasympathetic nervous system, leading to symptoms such as increased salivation, bronchoconstriction, and miosis. Tachycardia (A) is not typically associated with neostigmine use, oliguria (B) is not a common adverse effect, and xerostomia (C) is the opposite of the expected effect of increased salivation due to cholinergic stimulation.
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 information should the nurse include in the teaching for a school-age child with a new prescription for a fluticasone metered-dose inhaler? (Select all that apply)
- A. Soak the inhaler in water after use
- B. Have your child take one inhalation as needed for shortness of breath
- C. Shake the device prior to administration
- D. A spacer will make it easier to use the device
- E. Rinse your child's mouth following administration
Correct Answer: E
Rationale: The correct answer is E: Rinse your child's mouth following administration. Fluticasone is a corticosteroid inhaler that can cause oral thrush as a side effect. Rinsing the mouth after each use helps prevent this side effect. Choice A is incorrect because soaking the inhaler in water can damage the device. Choice B is incorrect because fluticasone is a maintenance medication, not a rescue inhaler for shortness of breath. Choice C is incorrect because shaking the device is not necessary for a metered-dose inhaler. Choice D is incorrect because while a spacer can help improve inhaler technique, it is not essential for using a metered-dose inhaler.