Nokea
A client has an anaphylactic reaction to penicillin that results in respiratory distress. Which of the following medications should the nurse anticipate administering?
- A. Dopamine (Intropin).
- B. Epinephrine.
- C. Albuterol (Proventil).
- D. Diphenhydramine (Benadryl).
Correct Answer: B
Rationale: Epinephrine is the first-line treatment for anaphylaxis, as it rapidly reverses respiratory distress and other symptoms by constricting blood vessels and relaxing airways.
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The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who? Select all that apply.
- A. Requires monitoring of prothrombin time due to Coumadin (warfarin) therapy.
- B. Has episodes of vertigo that result in falls.
- C. Has multiple sclerosis with an open, draining lesion on a foot.
- D. Needs stronger lenses for glasses.
Correct Answer: A,B,C
Rationale: Clients requiring prothrombin time monitoring, those with vertigo causing falls, and those with open lesions qualify for home care due to medical needs. Needing glasses does not typically require skilled home care services.
As a nurse preceptor, you are in the operating room with a student nurse. The client has received general anesthesia. The student nurse says, 'Oh no, the general anesthesia is not working. The client is shaking and moving.' How should you respond to this student nurse?
- A. The client is having anesthesia awareness which is not good.'
- B. This often happens during stage 2 of general anesthesia.'
- C. The client needs more general anesthesia.'
- D. The client is having a seizure.'
Correct Answer: B
Rationale: Shaking and moving during stage 2 (excitement phase) of general anesthesia is normal due to loss of inhibitory control before deeper anesthesia is achieved.
A client with a history of depression is prescribed escitalopram (Lexapro). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Suicidal thoughts.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Suicidal thoughts are a serious side effect of escitalopram, requiring immediate reporting to ensure client safety.
Clozapine (Clozaril) therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, 'Why do I have to have a blood test every week?' Which of the following responses by the nurse would be most appropriate?
- A. Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood.'
- B. Weekly blood tests are done so that you can receive another week's supply of the medication.'
- C. Your physician will want to know how well you are personally progressing with the medication therapy.'
- D. Everyone who takes this drug must go through the same procedure because it is required by the drug company.'
Correct Answer: A
Rationale: Weekly blood tests monitor for agranulocytosis, a serious side effect of clozapine, ensuring safe dosing and early detection of blood abnormalities.
A client is being treated with I.V. fluids for hypovolemic shock. Which of the following values is the best indicator that fluid resuscitation has been effective?
- A. Urine output of 30 mL/hour.
- B. Systolic blood pressure of 90 mm Hg.
- C. Respiratory rate of 22 breaths/minute.
- D. Pulse rate of 110 bpm.
Correct Answer: A
Rationale: A urine output of 30 mL/hour indicates adequate renal perfusion, a key sign of effective fluid resuscitation in hypovolemic shock.