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A client with chemotherapy-induced nausea receives a prescription for metoclopramide. Which adverse effect is most important for the nurse to report?
- A. Diarrhea.
- B. Unusual irritability.
- C. Nausea.
- D. Involuntary movements.
Correct Answer: D
Rationale: Involuntary movements (D), such as tardive dyskinesia, are a serious, potentially irreversible side effect of metoclopramide, requiring immediate reporting. Diarrhea (A) and irritability (B) are less severe. Nausea (C) is the treated condition, not an adverse effect.
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A patient in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system to manage asthma. This system delivers an inhaled powdered form of these combined medications. What instruction should the nurse provide to this patient’s caregivers?
- A. Instruct the patient to exhale rapidly into the mouthpiece when using the discus.
- B. Explain that the patient should not use the discus more than twice daily.
- C. Inform that patients using the discus may experience a decrease in blood pressure.
- D. Suggest offering the discus to the patient for use during an acute asthma attack.
Correct Answer: B
Rationale: Fluticasone/salmeterol is a maintenance therapy, used twice daily (B). Exhaling into the mouthpiece (A) is incorrect; inhalation is required. Hypotension (C) isn’t a common side effect. It’s not for acute attacks (D), which require rescue inhalers.
A patient with type 1 diabetes mellitus has been prescribed a glucagon emergency kit for home use. When should the nurse instruct the patient and family that glucagon needs to be administered?
- A. Before meals to prevent hyperglycemia.
- B. When signs of severe hypoglycemia occur.
- C. When unable to eat during sick days.
- D. At the onset of signs of diabetic ketoacidosis.
Correct Answer: B
Rationale: Glucagon treats severe hypoglycemia (B) by mobilizing liver glucose stores. It’s not for preventing hyperglycemia (A), sick-day management (C), or diabetic ketoacidosis (D), which requires insulin and medical intervention.
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.
The nurse is preparing to administer a scheduled dose of labetalol orally to a client with hypertension. The client’s vital signs are temperature 99° F (37.2 C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (BP) 150/90 mm Hg. What action should the nurse take?
- A. Withhold the scheduled dose and notify the healthcare provider.
- B. Administer the dose and monitor the client’s BP regularly.
- C. Assess for orthostatic hypotension before administering the dose.
- D. Apply a telemetry monitor before administering the dose.
Correct Answer: A
Rationale: Labetalol, a beta-blocker, can worsen bradycardia (heart rate 48 bpm). Withholding the dose and notifying the provider (A) is safest. Administering (B) risks exacerbating bradycardia. Orthostatic hypotension assessment (C) and telemetry (D) are secondary.
The nurse is administering sodium polystyrene sulfonate to a client with acute kidney injury (AKI). Which laboratory finding indicates that the medication has been effective?
- A. Serum potassium level of 3.8 mEq/L (3.8 mmol/L)
- B. Hemoglobin level of 13.5 g/dL (135 g/L).
- C. Serum glucose level of 120 mg/dL (6.7 mmol/L)
- D. Serum ammonia level of 30 Mcg/dL (17.62 Mermol/L)
Correct Answer: A
Rationale: Sodium polystyrene sulfonate treats hyperkalemia by exchanging sodium for potassium. A potassium level of 3.8 mEq/L (A) indicates effectiveness (normal range: 3.5-5.0 mEq/L). Hemoglobin (B), glucose (C), and ammonia (D) are unrelated to its action.