Nokea
A client with a history of multiple sclerosis is prescribed interferon beta-1a (Avonex). The nurse should instruct the client to report which of the following side effects immediately?
- A. Flu-like symptoms.
- B. Depression.
- C. Fatigue.
- D. Injection site redness.
Correct Answer: B
Rationale: Depression is a serious side effect of interferon beta-1a, requiring immediate reporting due to the risk of worsening mental health.
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Select the standardized 'hand off' change of shift reporting system that is accurately paired with its elements.
- A. SBAR: Symptoms, background, assessment and recommendations
- B. ISBAR: Interventions, symptoms, background, assessment and recommendations
- C. The Five Ps: The patient, plan, purpose, problems and precautions
- D. BATON: Background, assessment, timing, ownership and next plans
Correct Answer: C
Rationale: The Five Ps accurately describes a hand-off system with elements: patient, plan, purpose, problems, and precautions, used to ensure comprehensive communication during shift changes.
The nurse is caring for a client with a suspected tension pneumothorax. Which finding requires immediate action?
- A. Tracheal deviation
- B. Mild dyspnea
- C. Oxygen saturation of 92%
- D. Subcutaneous emphysema
Correct Answer: A
Rationale: Tracheal deviation is a life-threatening sign of tension pneumothorax, indicating mediastinal shift and requiring immediate decompression.
The nurse should suspect that the client taking disulfiram (Antabuse) has ingested alcohol when the client exhibits which of the following symptoms?
- A. Sore throat and muscle aches.
- B. Nausea and flushing of the face and neck.
- C. Fever and muscle soreness.
- D. Bradycardia and vertigo.
Correct Answer: B
Rationale: Disulfiram causes an adverse reaction with alcohol, leading to symptoms like nausea and flushing due to acetaldehyde accumulation.
A client has atrial fibrillation. The nurse should monitor the client for:
- A. Cardiac arrest
- B. Cerebrovascular accident
- C. Heart block
- D. Ventricular fibrillation
Correct Answer: B
Rationale: Atrial fibrillation increases the risk of thromboembolism, leading to cerebrovascular accident (stroke). Cardiac arrest, heart block, and ventricular fibrillation are less directly associated.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed sotalol (Betapace). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Hyperglycemia.
- D. Weight gain.
Correct Answer: B
Rationale: Sotalol, a beta-blocker, can cause bradycardia, requiring close monitoring of heart rate.