Nokea
A nurse in a provider's office is collecting data from a client who continues to have a migraine headache after taking sumatriptan orally 2 hr ago. Which of the following findings is the priority for the nurse to report?
- A. Tingling sensation
- B. Hypertension
- C. Dizziness
- D. Flushing
Correct Answer: B
Rationale: The correct answer is B: Hypertension. This is the priority finding for the nurse to report because sumatriptan, a medication used for migraines, can potentially cause a rare but serious side effect of increased blood pressure. Hypertension can lead to severe complications such as stroke or heart attack. Reporting hypertension promptly allows for timely intervention to prevent harm.
Other choices are less urgent:
A: Tingling sensation is a common side effect of sumatriptan and usually resolves on its own.
C: Dizziness may occur with sumatriptan but is not as concerning as hypertension.
D: Flushing is a common side effect and does not require immediate action like hypertension.
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A nurse in a clinic is preparing to administer the measles, mumps, rubella (MMR) vaccine to a client. Which of the following findings should indicate to the nurse that the client has a contraindication for the MMR vaccine?
- A. The client had a local reaction from a previous immunization
- B. The client reports having diarrhea this morning
- C. The client is at 9 weeks of gestation
- D. The client reports an allergy to penicillin.
Correct Answer: C
Rationale: The correct answer is C: The client is at 9 weeks of gestation. Administering the MMR vaccine during pregnancy is contraindicated due to the theoretical risk of causing harm to the fetus. The live attenuated MMR vaccine should not be given to pregnant women as it may potentially harm the developing fetus. It is crucial to avoid administration during pregnancy to prevent any adverse effects on the unborn child.
Other options are incorrect because:
A: The client had a local reaction from a previous immunization - Local reactions to previous vaccines are not contraindications to receiving the MMR vaccine.
B: The client reports having diarrhea this morning - Diarrhea is not a contraindication for the MMR vaccine.
D: The client reports an allergy to penicillin - Allergy to penicillin is not a contraindication for the MMR vaccine.
A nurse is checking the forearm of a client who received a tuberculin skin test 48 hr ago. Which of the following findings at the injection site should indicate to the nurse a positive result?
- A. Excoriation
- B. Firmness
- C. Ulceration
- D. Bleeding
Correct Answer: B
Rationale: The correct answer is B: Firmness. A positive tuberculin skin test is indicated by induration (firmness) at the injection site, not redness, swelling, or pain. Induration of 10mm or more is considered positive for most individuals. Excoriation (choice A) refers to scratching or scraping of the skin, not a typical sign of a positive tuberculin skin test. Ulceration (choice C) involves open sores, not related to a tuberculin skin test. Bleeding (choice D) at the injection site is not a sign of a positive result.
A nurse is caring for a client who is taking alendronate to treat osteoporosis. The nurse should monitor for which of the following adverse effects?
- A. Drowsiness
- B. Dyskinesia
- C. Musculoskeletal pain
- D. Weight gain
Correct Answer: C
Rationale: The correct answer is C: Musculoskeletal pain. Alendronate is a bisphosphonate used to treat osteoporosis. It can cause musculoskeletal pain as a common adverse effect due to its impact on bone turnover. Monitoring for this adverse effect is essential to ensure patient safety. Drowsiness (A), dyskinesia (B), and weight gain (D) are not typically associated with alendronate use, making them incorrect choices. It is important to focus on the specific pharmacological effects and common adverse reactions of medications to determine the correct answer.
A nurse is caring for a client who is experiencing acute alcohol withdrawal. The nurse should anticipate administering which of the following medications to the client to facilitate the withdrawal process?
- A. Varenicline
- B. Diazepam
- C. Clonidine
- D. Methadone
Correct Answer: B
Rationale: The correct answer is B: Diazepam. Diazepam is a benzodiazepine that is commonly used to manage acute alcohol withdrawal symptoms by reducing anxiety, agitation, and preventing seizures. It acts on the GABA receptors to produce a calming effect. Varenicline (A) is used for smoking cessation, not alcohol withdrawal. Clonidine (C) is mainly used for hypertension and opioid withdrawal, not alcohol withdrawal. Methadone (D) is used for opioid dependence, not alcohol withdrawal.
A nurse is caring for a client who has prescriptions for spironolactone and lisinopril. The nurse should monitor for which of the following adverse effects?
- A. Hypoglycemia
- B. Hyperkalemia
- C. Hyperglycemia
- D. Hypokalemia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic and can lead to an increase in potassium levels (hyperkalemia). Lisinopril, an ACE inhibitor, can also contribute to this effect. Monitoring for hyperkalemia is crucial as it can lead to serious cardiac complications.
A: Hypoglycemia is not typically associated with spironolactone or lisinopril.
C: Hyperglycemia is not a common adverse effect of spironolactone or lisinopril.
D: Hypokalemia is unlikely with spironolactone, as it tends to increase potassium levels.
In summary, monitoring for hyperkalemia is essential when a client is taking spironolactone and lisinopril due to the potential for adverse cardiac events.