Nokea
A nurse is administering naloxone to a client who has developed an adverse reaction to morphine. The nurse should identify which of the following findings as a therapeutic effect of naloxone?
- A. Decreased nausea
- B. Increased pain relief
- C. Decreased blood pressure
- D. Increased respiratory rate
Correct Answer: D
Rationale: The correct answer is D: Increased respiratory rate. Naloxone is an opioid antagonist that works by blocking the effects of opioids, such as morphine. By administering naloxone to the client experiencing an adverse reaction to morphine, the nurse can reverse the respiratory depression caused by the morphine. This reversal leads to an increase in the client's respiratory rate, which is a therapeutic effect of naloxone in this situation.
Incorrect choices:
A: Decreased nausea - Naloxone does not directly address nausea.
B: Increased pain relief - Naloxone does not provide pain relief but reverses the effects of opioids.
C: Decreased blood pressure - Naloxone may lead to an increase in blood pressure due to its effects on reversing opioid-induced respiratory depression.
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A nurse is consulting a formulary about a client's new prescription for raloxifene. The nurse should identify that this medication is used to treat which of the following conditions?
- A. Osteoporosis
- B. Hypothyroidism
- C. Urinary tract infection
Correct Answer: A
Rationale: The correct answer is A: Osteoporosis. Raloxifene is a medication used to prevent and treat osteoporosis by increasing bone density. It is a selective estrogen receptor modulator that mimics estrogen's effects on bone without affecting other tissues like the uterus. This helps to reduce the risk of fractures in postmenopausal women. Choices B, C, D, E, F, and G are incorrect because raloxifene is not indicated for hypothyroidism, urinary tract infections, or any other conditions besides osteoporosis.
A nurse is mixing regular insulin and NPH insulin in the same syringe prior to administering it to a client who has diabetes mellitus. Which of the following actions should the nurse take first?
- A. Withdraw the regular insulin from the vial
- B. Withdraw the NPH insulin from the vial
- C. Inject air into the NPH vial
- D. Inject air into the regular insulin vial
Correct Answer: C
Rationale: The correct answer is C: Inject air into the NPH vial. This step is crucial to prevent creating a vacuum in the vial when withdrawing the NPH insulin, ensuring accurate dosage measurement. Injecting air into the NPH vial equalizes pressure, making it easier to withdraw the correct amount of insulin without causing air bubbles.
Choice A is incorrect as withdrawing regular insulin first may lead to air being drawn into the syringe when withdrawing NPH insulin. Choice B is incorrect because withdrawing NPH insulin first without equalizing pressure may cause difficulty in drawing the correct amount of insulin. Choice D is incorrect as injecting air into the regular insulin vial before withdrawing NPH insulin is unnecessary and may introduce air bubbles into the syringe.
A client who has active tuberculosis and is taking rifampin reports that his urine and sweat have developed a red tinge. Which of the following actions should the nurse take?
- A. Check the client's liver function test results.
- B. Instruct the client to increase his fluid intake.
- C. Document this as an expected finding.
- D. Prepare the client for dialysis.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Document this as an expected finding. Rifampin is known to cause harmless discoloration of bodily fluids like urine and sweat. This is a common side effect and does not indicate any serious issues. The nurse should document this finding to track the client's response to the medication and educate the client about it.
Summary of Incorrect Choices:
A: Checking liver function test results is not necessary for the red discoloration caused by rifampin.
B: Increasing fluid intake will not resolve the red tinge as it is a known side effect of rifampin.
D: Dialysis is not indicated for the harmless discoloration caused by rifampin.
A nurse is reviewing a client's 0800 laboratory values at 1100. The nurse notes that the client received heparin at 1000. Which of the following laboratory values warrants an incident report?
- A. ePTT 90 seconds
- B. Hgb 16 g/dL
- C. INR 1.6
- D. WBC 6,000/mm3
Correct Answer: A
Rationale: The correct answer is A: ePTT 90 seconds. This value indicates a higher than normal clotting time, which could potentially lead to bleeding complications due to excessive anticoagulation from heparin. The other values (B, C, D) are within normal ranges and do not indicate an immediate risk or adverse outcome related to heparin administration. An incident report is necessary to document and address the elevated ePTT to ensure appropriate interventions are taken to prevent harm to the patient.
A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following as an indication of an allergic reaction following the injection?
- A. Urticaria
- B. Bradycardia
- C. Pallor
- D. Dyspepsia
Correct Answer: A
Rationale: The correct answer is A: Urticaria. Urticaria, or hives, is a classic sign of an allergic reaction. It presents as raised, red, itchy welts on the skin. This occurs due to histamine release in response to the allergen (penicillin in this case). Monitoring for urticaria is crucial as it indicates a potentially serious allergic reaction that may progress to anaphylaxis. Bradycardia (B), Pallor (C), and Dyspepsia (D) are not typically associated with allergic reactions to penicillin. Bradycardia is a slow heart rate, pallor is paleness of the skin, and dyspepsia is indigestion. These symptoms are more likely related to other conditions or side effects rather than an allergic reaction.