Nokea
A client with a diagnosis of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following side effects?
- A. Infection.
- B. Hypotension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Etanercept, a TNF inhibitor, increases the risk of infections due to immune suppression.
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A client with a history of heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hyperkalemia.
- B. Hypokalemia.
- C. Hypernatremia.
- D. Hypocalcemia.
Correct Answer: B
Rationale: Furosemide, a loop diuretic, can cause hypokalemia by increasing potassium excretion in the urine.
When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis?
- A. Improved muscle strength after I.V. administration of edrophonium chloride (Tensilon).
- B. Increased weakness.
- C. Diaphoresis.
- D. Increased salivation.
Correct Answer: A
Rationale: Improved muscle strength after edrophonium indicates myasthenic crisis, not cholinergic crisis, which involves excessive anticholinesterase effects.
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
- A. Administer acetaminophen.
- B. Take the client's blood pressure.
- C. Discontinue the transfusion.
- D. Check the infusion rate of the blood.
Correct Answer: C
Rationale: Chills and headache suggest a transfusion reaction, requiring immediate discontinuation of the transfusion to prevent further complications.
The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement?
- A. Discontinue the current TPN infusion.
- B. Decrease the infusion rate of the TPN.
- C. Replace TPN with 5% dextrose solution.
- D. Confer with provider for glucose control.
Correct Answer: D
Rationale: A glucose level of 400 mg/dL indicates significant hyperglycemia, which is a potential complication of TPN due to its high dextrose content. The nurse should confer with the primary health care provider to obtain orders for glucose control, such as insulin administration, to manage the hyperglycemia safely. Discontinuing or altering the TPN infusion without provider orders is inappropriate, as TPN is a critical nutrition source, and abrupt changes could cause metabolic imbalances. Replacing TPN with 5% dextrose would not address the hyperglycemia and could exacerbate it.
Methylergonovine maleate is prescribed for a woman who has just delivered a healthy newborn. Which is the priority assessment to complete before administering the medication?
- A. Lochia
- B. Uterine tone
- C. Blood pressure
- D. Deep tendon reflexes
Correct Answer: C
Rationale: Methylergonovine maleate, an oxytocic, is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose is administered intramuscularly, and then, if still needed, it is administered orally. It causes uterine contractions and may elevate the blood pressure. A priority assessment before administration of methylergonovine maleate is blood pressure. Methylergonovine maleate is to be administered cautiously in the presence of hypertension, and the primary health care provider should be notified if hypertension is present. Options 1 and 2 are general components of care in the postpartum period. Option 4 is most specifically related to the administration of magnesium sulfate.