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?
- A. Gingival hyperplasia
- B. Weight gain
- C. Insomnia
- D. Dry skin
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia, which requires monitoring and dental care. Weight gain, insomnia, and dry skin are not common side effects.
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Which site or technique would you expect to use to administer ferrous sulfate?
- A. A subcutaneous injection site
- B. The PQRST technique
- C. The Z track technique
- D. The sublingual site
Correct Answer: C
Rationale: The Z-track technique is used for ferrous sulfate IM injections to prevent leakage and skin staining.
A 19-year-old G1 P0 is being discharged home after hospitalization for hyperemesis gravidarum and is being referred to home health care. The nurse should develop a discharge plan that includes which of the following? Select all that apply.
- A. Refer client to a nutritionist for the following day.
- B. Ensure that the client has a prescription for an antiemetic.
- C. Ask the health care provider (HCP) for an anxiolytic prescription.
- D. Encourage return to normal routine when client feels ready.
- E. Coordinate follow-up appointment with provider in 6 weeks.
- F. Discuss plan of care and discharge instructions with client.
Correct Answer: A, B, D, F
Rationale: For hyperemesis gravidarum, a nutritionist referral, antiemetic prescription, gradual return to routine, and discussing discharge instructions are essential. Anxiolytics may not be indicated, and a 6-week follow-up is too delayed.
A client has been prescribed cyclobenzaprine for the management of muscle spasms. The nurse should observe the client for which most frequent side effect?
- A. Fatigue
- B. Irritability
- C. Excitability
- D. Drowsiness
Correct Answer: D
Rationale: The most frequent side effects of cyclobenzaprine are drowsiness, dizziness, and dry mouth. This medication is a centrally acting skeletal muscle relaxant used in the management of muscle spasms that accompany a variety of conditions. Fatigue, nervousness, and confusion are rare side effects of the medication.
Which of the following is an essential component for insuring that medical equipment is being used safely and properly by those who you supervise?
- A. Education and training on all pieces of equipment
- B. Pilot testing new equipment
- C. Reading all the manufacturer's instructions
- D. Researching the equipment before recommending its purchase
Correct Answer: A
Rationale: Education and training on all pieces of equipment is essential to ensure staff can use equipment safely and correctly, reducing risks to clients and staff.
A client reports gas pains after surgery and requests medication. The nurse reviews the medication prescription sheet to see if which medication is prescribed for the relief of gas pains?
- A. Droperidol
- B. Simethicone
- C. Acetaminophen
- D. Magnesium hydroxide
Correct Answer: B
Rationale: Simethicone is an antiflatulent used in the relief of pain caused by excessive gas in the gastrointestinal tract. Droperidol is used to treat postoperative nausea and vomiting. Acetaminophen is a nonopioid analgesic. Magnesium hydroxide is an antacid and laxative.