Nokea
A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Nausea.
- B. Gingival hyperplasia.
- C. Rash.
- D. Drowsiness.
Correct Answer: C
Rationale: A rash may indicate a serious hypersensitivity reaction to phenytoin, such as Stevens-Johnson syndrome, requiring immediate reporting.
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A client with a history of heart failure is prescribed losartan (Cozaar). The nurse should monitor the client for which of the following side effects?
- A. Hyperkalemia.
- B. Hypoglycemia.
- C. Weight gain.
- D. Hypertension.
Correct Answer: A
Rationale: Losartan, an ARB, can cause hyperkalemia, requiring monitoring of potassium levels.
The nurse is preparing to implement emergency care measures for the client who has just demonstrated signs and symptoms of a pulmonary embolism. Which primary health care provider prescription should the nurse implement first?
- A. Apply oxygen.
- B. Administer morphine sulfate.
- C. Start an intravenous (IV) line.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: The client needs oxygen immediately because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should also have an IV line for the administration of emergency medications such as morphine sulfate. An ECG is useful in determining the presence of possible right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first.
A client is reporting skin irritation from the edges of a cast that was applied the previous day. The nurse notes that the skin is pink and irritated. Which corrective action should the nurse take?
- A. Petal the edges of the cast with tape.
- B. Massage the skin at the rim of the cast.
- C. Shake a small amount of powder under the cast rim.
- D. Use a hair dryer set on a cool high setting to soothe the irritation.
Correct Answer: A
Rationale: The nurse should petal the edges of the cast with tape to minimize skin irritation. Massaging the skin will not help the problem. Powder should not be shaken under the cast because it could clump, become moist, and cause skin breakdown. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet or if the client's skin itches under a cast.
A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge?
- A. I will implement my exercise program as soon as I get home.'
- B. I will be careful not to cross my legs.'
- C. I will need an elevated toilet seat.'
- D. I can't wait to take a tub bath when I get home.'
Correct Answer: D
Rationale: Tub baths are contraindicated post-hip replacement due to the risk of hip flexion beyond 90 degrees, indicating a need for further teaching.
A client with cirrhosis is admitted with ascites. The nurse should monitor the client for which of the following complications?
- A. Respiratory distress.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Hypertension.
Correct Answer: A
Rationale: Ascites can cause diaphragmatic compression, leading to respiratory distress, which requires monitoring.