Nokea
A client is receiving meperidine (Demerol) for pain management. Which assessment finding requires immediate action?
- A. Constipation
- B. Drowsiness
- C. Respiratory rate of 10 breaths per minute
- D. Nausea
Correct Answer: C
Rationale: A respiratory rate of 10 breaths per minute indicates respiratory depression, a severe side effect of meperidine (Demerol) that necessitates immediate intervention to prevent further complications. Constipation, drowsiness, and nausea are common but less urgent side effects that do not pose an immediate life-threatening risk.
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During an admission assessment, a client informs the nurse that they take propylthiouracil (PTU) daily. Based on this information, the nurse suspects that the client has a history of:
- A. Myxedema
- B. Graves' disease
- C. Addison's disease
- D. Cushing's syndrome
Correct Answer: B
Rationale: Propylthiouracil (PTU) is a medication commonly used to treat hyperthyroidism, including Graves' disease, which is characterized by an overactive thyroid gland. The client mentioning the daily use of PTU indicates that they likely have a history of Graves' disease, as this medication helps manage the condition by reducing the production of thyroid hormones. Therefore, the correct answer is B: Graves' disease.
A client is taking lansoprazole (Prevacid) for the chronic management of Zollinger-Ellison syndrome. The nurse advises the client to take which of the following products if needed for a headache?
- A. Naproxen (Aleve)
- B. Ibuprofen (Advil)
- C. Acetaminophen (Tylenol)
- D. Acetylsalicylic acid (aspirin)
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client with non-Hodgkin's lymphoma is receiving daunorubicin (DaunoXome). Which of the following would indicate to the nurse that the client is experiencing a toxic effect related to the medication?
- A. Fever
- B. Diarrhea
- C. Complaints of nausea and vomiting
- D. Crackles on auscultation of the lungs
Correct Answer: D
Rationale: Crackles on auscultation of the lungs would indicate a toxic effect related to daunorubicin, known to cause cardiotoxicity. Cardiotoxicity can manifest as heart failure, abnormal ECG findings, or cardiomyopathy. It is crucial for the nurse to monitor for signs of cardiotoxicity to ensure timely intervention and prevent further complications.
Intravenous heparin therapy is prescribed for a client. While implementing this prescription, a nurse ensures that which of the following medications is available on the nursing unit?
- A. Protamine sulfate
- B. Potassium chloride
- C. Phytonadione (vitamin K)
- D. Aminocaproic acid (Amicar)
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A healthcare professional is monitoring a client who is receiving intravenous amphotericin B. Which of the following should prompt the healthcare professional to notify the healthcare provider immediately?
- A. Fever
- B. Headache
- C. Nausea
- D. Oliguria
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.