Nokea
A client with Parkinson's disease is prescribed levodopa-carbidopa. Which side effect should the nurse monitor for?
- A. Hypertension.
- B. Dyskinesia.
- C. Hypoglycemia.
- D. Weight gain.
Correct Answer: B
Rationale: Dyskinesia, involuntary movements, is a common side effect of levodopa-carbidopa due to dopamine overstimulation.
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Which of the following is true with regard to delegation of client care responsibilities? Select all that apply.
- A. The nurse must know the nursing model that underlies care at the institution.
- B. The nurse delegates in accordance with demands on his/her time.
- C. The nurse validates with the non-RN caregiver that he/she has performed the same activity before.
- D. The nurse retains the right to determine which tasks are delegated.
- E. The nurse must account that the task has been delegated and to whom.
Correct Answer: A, C, D, E
Rationale: Delegation involves understanding the care model, validating caregiver competency, determining tasks, and documenting delegation, but not delegating based solely on time demands.
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.
The nurse is caring for a client in labor who has butorphanol tartrate prescribed for the relief of labor pain. During the administration of the medication, the nurse should ensure that which priority item is readily available?
- A. Naloxone
- B. Meperidine hydrochloride
- C. An intravenous form of an antiemetic
- D. An intravenous solution of normal saline
Correct Answer: A
Rationale: Butorphanol tartrate is an opioid analgesic that provides systemic pain relief during labor. The nurse should ensure that naloxone and resuscitation equipment are readily available to treat respiratory depression, should it occur. Meperidine hydrochloride is also an opioid analgesic that may be used for pain relief, but it also causes respiratory depression. Although an antiemetic may be prescribed for vomiting, antiemetics may enhance the respiratory depressant effects of the butorphanol tartrate. Although an IV access is desirable, the administration of normal saline is unrelated to the administration of this medication.
A client was treated for a streptococcal throat infection 2 weeks ago. The client now has been diagnosed with acute poststreptococcal glomerulonephritis. The client asks the nurse how he could have prevented this condition. What should the nurse tell the client?
- A. See your physician for an early diagnosis and treatment of a sore throat.'
- B. As long as you do not have a fever, it is sufficient to gargle daily with an antibacterial mouthwash.'
- C. You may continue to utilize the previously prescribed antibiotics until they are gone.'
- D. Unscented bar soap may be used in showers.'
Correct Answer: A
Rationale: Early diagnosis and treatment of streptococcal infections prevent complications like glomerulonephritis. Mouthwash, leftover antibiotics, or soap use are not preventive measures.
A 30-year-old client is hospitalized with a fractured femur, which is being treated with skeletal traction. He states that he has not had a bowel movement for 2 days. Which of the following interventions is most appropriate at this time?
- A. Administer a tap water enema.
- B. Place the client on the bedpan every 2 to 3 hours.
- C. Increase the client's fluid intake to 3,000 mL/day.
- D. Perform range-of-motion movements to all extremities.
Correct Answer: C
Rationale: Increasing fluid intake promotes bowel motility, addressing constipation in a client immobilized by traction.