Nokea
A client has been prescribed cyclobenzaprine for the management of muscle spasms. The nurse should observe the client for which most frequent side effect?
- A. Fatigue
- B. Irritability
- C. Excitability
- D. Drowsiness
Correct Answer: D
Rationale: The most frequent side effects of cyclobenzaprine are drowsiness, dizziness, and dry mouth. This medication is a centrally acting skeletal muscle relaxant used in the management of muscle spasms that accompany a variety of conditions. Fatigue, nervousness, and confusion are rare side effects of the medication.
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A client reports gas pains after surgery and requests medication. The nurse reviews the medication prescription sheet to see if which medication is prescribed for the relief of gas pains?
- A. Droperidol
- B. Simethicone
- C. Acetaminophen
- D. Magnesium hydroxide
Correct Answer: B
Rationale: Simethicone is an antiflatulent used in the relief of pain caused by excessive gas in the gastrointestinal tract. Droperidol is used to treat postoperative nausea and vomiting. Acetaminophen is a nonopioid analgesic. Magnesium hydroxide is an antacid and laxative.
You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client?
- A. A percutaneous, non tunneled subclavian catheter
- B. A peripheral intravenous catheter that is 20 gauge
- C. A multi lumen implanted tunneled and cuffed central venous catheter
- D. A peripherally inserted central venous catheter
Correct Answer: C
Rationale: A multi-lumen tunneled and cuffed central venous catheter is ideal for long-term therapy due to its durability and lower infection risk.
A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother?
- A. What do you think about having your mother leave the room?'
- B. Mother, do you think your daughter is sexually active?'
- C. Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter.'
- D. The two of you seem like you share everything. I am going to ask questions about sexual history now.'
Correct Answer: C
Rationale: Requesting the mother to leave ensures privacy for the teen, promoting honest responses during the sexual history.
A 30-year-old client is hospitalized with a fractured femur, which is being treated with skeletal traction. He states that he has not had a bowel movement for 2 days. Which of the following interventions is most appropriate at this time?
- A. Administer a tap water enema.
- B. Place the client on the bedpan every 2 to 3 hours.
- C. Increase the client's fluid intake to 3,000 mL/day.
- D. Perform range-of-motion movements to all extremities.
Correct Answer: C
Rationale: Increasing fluid intake promotes bowel motility, addressing constipation in a client immobilized by traction.
A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal delivery. The physician has ordered I.M. prostagland in F₂a. After administration of the medication, the nurse should observe the client for which of the following?
- A. Tachycardia
- B. Hypotension
- C. Constipation
- D. Fever
Correct Answer: A
Rationale: Prostaglandin-F2α can cause tachycardia as a side effect due to its stimulatory effects on smooth muscle. Hypotension, constipation, and fever are less commonly associated.