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A client reports confusion and blurred vision after receiving a dose of glipizide. What should the nurse do?
- A. Administer glucagon intramuscularly.
- B. Measure the client’s vital signs.
- C. Obtain a fingerstick blood glucose.
- D. Perform a neurological exam.
Correct Answer: C
Rationale: Glipizide, a sulfonylurea, can cause hypoglycemia, presenting as confusion and blurred vision. Checking blood glucose (C) confirms the cause. Glucagon (A) treats severe hypoglycemia, not confirmed yet. Vital signs (B) and neurological exams (D) are secondary.
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A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this client’s plan of care?
- A. Replace salt with a salt substitute.
- B. Cover your skin before going outside.
- C. Limit intake of high-potassium foods.
- D. Monitor skin for excessive bruising.
Correct Answer: C
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia. Limiting high-potassium foods (C) prevents this risk. Salt substitutes (A) often contain potassium, worsening hyperkalemia. Sun protection (B) and bruising (D) are unrelated to spironolactone’s primary risks.
A patient with nasal congestion has been prescribed phenylephrine 10 mg by mouth every 4 hours. What patient condition should the nurse report to the healthcare provider before administering the medication?
- A. Hypertension.
- B. Bronchitis.
- C. Diarrhea.
- D. Edema.
Correct Answer: A
Rationale: Phenylephrine, a decongestant, can raise blood pressure, making hypertension (A) a contraindication requiring provider consultation. Bronchitis (B), diarrhea (C), and edema (D) are not directly affected by phenylephrine.
A client has a new prescription for zolpidem, a hypnotic. The client tells the home health nurse that he plans to take a dose of the medication during the day because he is exhausted and needs to take a short afternoon nap prior to an evening activity in his home. Which action should the nurse take?
- A. Explain that the client needs to allow for sleep time of at least two hours.
- B. Advise the client to take the medication with the noon meal.
- C. Encourage the client to wait until bedtime to take the medication.
- D. Remind the client to drink plenty of fluids when taking the medication.
Correct Answer: C
Rationale: Zolpidem, a sedative-hypnotic, should be taken at bedtime (C) to avoid daytime drowsiness and fall risk. Two hours of sleep (A) is insufficient for safe clearance. Taking with meals (B) reduces efficacy. Fluid intake (D) is unrelated to zolpidem’s administration.
The nurse initiates an infusion of piperacillin-tazobactam for a client with a urinary tract infection. Five minutes into the infusion, the client reports not feeling well. Which client manifestation should the nurse identify as a reason to stop the infusion?
- A. Hypertension.
- B. Scratchy throat.
- C. Bradycardia.
- D. Pupillary constriction.
Correct Answer: B
Rationale: A scratchy throat (B) may indicate an allergic reaction, potentially anaphylaxis, requiring immediate cessation of the piperacillin-tazobactam infusion and assessment. Hypertension (A), bradycardia (C), and pupillary constriction (D) are not typical signs of an allergic response to this antibiotic.
A client with benign prostatic hyperplasia has been prescribed tamsulosin. What should the nurse do to monitor for an adverse reaction?
- A. Monitor the client’s blood pressure.
- B. Assess the client’s urine output.
- C. Perform a bladder scan.
- D. Obtain the client’s daily weights.
Correct Answer: A
Rationale: Tamsulosin, an alpha-blocker, can cause hypotension and dizziness (A), requiring blood pressure monitoring. Urine output (B) and bladder scans (C) assess BPH, not adverse effects. Daily weights (D) monitor fluid status, not tamsulosin risks.