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A client is prescribed digoxin 0.125 mg daily for heart failure. Which of the following client reports should concern the nurse as a sign of digoxin toxicity?
- A. Increased appetite
- B. Visual disturbances
- C. Weight gain
- D. Constipation
Correct Answer: B
Rationale: Visual disturbances such as blurred vision or seeing halos around lights are common signs of digoxin toxicity. Increased appetite, weight gain, and constipation are not typically associated with digoxin toxicity. Weight gain could be a sign of worsening heart failure rather than digoxin toxicity. Increased appetite and constipation are not specific signs of digoxin toxicity and are less likely to be related.
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A nurse is providing care to a client with staphylococcus epidermidis who is prescribed vancomycin. Identify the adverse effect associated with the antibiotic therapy.
- A. Hepatotoxicity
- B. Constipation
- C. Infusion reaction
- D. Immunosuppression
Correct Answer: C
Rationale: The correct answer is C: Infusion reaction. Vancomycin can cause infusion reactions like 'Red Man Syndrome,' which involves rashes, flushing, tachycardia, and hypotension. Hepatotoxicity (choice A) is not a common adverse effect of vancomycin. Constipation (choice B) is not typically associated with vancomycin use. Immunosuppression (choice D) is not a direct adverse effect of vancomycin therapy.
A nurse is caring for a client taking ciprofloxacin for an infection. Which of the following adverse effects should the nurse include in the client education?
- A. Constipation
- B. Tendon rupture
- C. Dry mouth
- D. Nasal congestion
Correct Answer: B
Rationale: The correct answer is B: Tendon rupture. Ciprofloxacin belongs to the fluoroquinolone class of antibiotics, which is associated with the adverse effect of tendon rupture. Tendon rupture is a severe but rare side effect that can occur with the use of ciprofloxacin. Educating the client about this potential adverse effect is crucial to promote awareness and early recognition of symptoms, such as tendon pain, swelling, or inflammation. Choices A, C, and D are not typically associated with ciprofloxacin use and are less relevant for client education in this scenario.
When administering amlodipine to a client with hypertension, what adverse effect should the nurse monitor for?
- A. Constipation
- B. Facial flushing
- C. Hypotension
- D. Jaundice
Correct Answer: C
Rationale: The correct answer is C, Hypotension. Amlodipine is a calcium channel blocker commonly used to treat hypertension. One of the main adverse effects of amlodipine is hypotension, leading to low blood pressure. The nurse should monitor the client for signs of hypotension such as dizziness, lightheadedness, or fainting. Choices A, B, and D are incorrect because constipation, facial flushing, and jaundice are not typically associated with amlodipine administration.
A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose?
- A. 0.2 mL
- B. 0.4 mL
- C. 0.6 mL
- D. 0.8 mL
Correct Answer: A
Rationale: The nurse should administer 0.2 mL of morphine sulfate. To calculate this, divide the desired dose (2 mg) by the concentration of the available solution (10 mg/mL). 2 mg / 10 mg/mL = 0.2 mL. Therefore, the nurse should administer 0.2 mL of morphine sulfate. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the provided concentration and desired dose.
Before administering blood products, which action should be taken?
- A. Assess the client's temperature
- B. Document client response
- C. Prime IV tubing with 0.45% sodium chloride
- D. Administer epinephrine
Correct Answer: A
Rationale: Correct answer: Before administering blood products, the client's temperature must be assessed to establish a baseline and monitor for transfusion reactions. Choice B is incorrect because documenting client response should occur after administering the blood products. Choice C is incorrect as priming IV tubing with 0.45% sodium chloride is not directly related to assessing the client before administering blood products. Choice D is incorrect because administering epinephrine is not a routine action before administering blood products.