Nokea
A client is diagnosed with pulmonary embolism and is to be treated with streptokinase (Streptase). A nurse would report which priority data collection finding to the registered nurse before initiating this therapy?
- A. Adventitious breath sounds
- B. Temperature of 99.4°F orally
- C. Blood pressure of 198/110 mm Hg
- D. Respiratory rate of 28 breaths/min
Correct Answer: C
Rationale: The correct answer is C. Streptokinase therapy is contraindicated in severe uncontrolled hypertension due to the risk of cerebral hemorrhage. A blood pressure of 198/110 mm Hg indicates severe hypertension, which needs to be addressed before initiating streptokinase to prevent potential complications.
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A home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which of the following statements, if made by the client, indicates the need for further education?
- A. Constipation and bloating might be a problem.
- B. I'll continue to watch my diet and reduce my fats.
- C. Walking a mile each day will help the whole process.
- D. I'll continue my nicotinic acid from the health food store.
Correct Answer: D
Rationale: Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.
A client is being cared for by a nurse due to severe back pain, and codeine sulfate has been prescribed. Which of the following should the nurse include in the plan of care while the client is taking this medication?
- A. Restrict fluid intake.
- B. Monitor bowel activity.
- C. Monitor for hypertension.
- D. Monitor peripheral pulses.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is taking propranolol (Inderal LA). Which data collection finding would indicate a potential serious complication associated with propranolol?
- A. The development of complaints of insomnia
- B. The development of audible expiratory wheezes
- C. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication
- D. A baseline resting heart rate of 88 beats/min followed by a resting heart rate of 72 beats/min after two doses of the medication
Correct Answer: B
Rationale: The development of audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm, associated with propranolol. Beta-blockers can trigger bronchospasm, especially in clients with chronic obstructive pulmonary disease or asthma. This complication can lead to significant respiratory distress and should be addressed promptly to prevent further complications.
A client with hypertension is prescribed losartan (Cozaar). Which instruction should the nurse include in the teaching plan?
- A. Avoid foods high in potassium.
- B. Take the medication with grapefruit juice.
- C. Monitor blood pressure weekly.
- D. Report any swelling of the lips or face.
Correct Answer: D
Rationale: The correct instruction for a client prescribed losartan (Cozaar) is to report any swelling of the lips or face. Losartan can cause angioedema, which is a serious side effect that requires immediate medical attention. Clients do not need to avoid potassium-rich foods unless specifically instructed by their healthcare provider. Taking the medication with grapefruit juice is not recommended as it can interact with certain medications. Additionally, monitoring blood pressure regularly is important, but it should not be limited to a weekly basis; blood pressure should be monitored as per the healthcare provider's recommendation.
Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse monitors for which side effects of the medication? Select one that doesn't apply.
- A. Signs of hepatitis
- B. Flu-like syndrome
- C. Low neutrophil count
- D. Vitamin B6 deficiency
Correct Answer: D
Rationale: Rifabutin is known to cause side effects such as hepatitis, flu-like syndrome, low neutrophil count, and ocular pain or blurred vision. Vitamin B6 deficiency is not associated with rifabutin but is a side effect of isoniazid (INH). Therefore, the nurse should not monitor for Vitamin B6 deficiency when administering rifabutin.