Nokea
A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following should the nurse identify as an adverse effect of this medication?
- A. Hypoglycemia
- B. Bradycardia
- C. Red man syndrome
- D. Hypotension
Correct Answer: D
Rationale: The correct answer is D: Hypotension. Phenytoin can cause hypotension as an adverse effect due to its vasodilatory properties. The drug can cause a decrease in blood pressure, leading to symptoms such as dizziness and lightheadedness. This adverse effect is important for the nurse to recognize as it can potentially lead to complications such as falls in the client.
A: Hypoglycemia is not a common adverse effect of phenytoin.
B: Bradycardia is not a typical adverse effect of phenytoin.
C: Red man syndrome is associated with vancomycin, not phenytoin.
Summary: Phenytoin is more likely to cause hypotension as an adverse effect, rather than hypoglycemia, bradycardia, or red man syndrome.
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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 reviewing the laboratory values of a client who is taking atorvastatin. Which of the following laboratory values indicates the treatment has been effective?
- A. BUN 15 mg/dL
- B. Blood glucose 90 mg/dL
- C. Urine specific gravity 1.020
- D. LDL 120 mg/dL
Correct Answer: D
Rationale: The correct answer is D: LDL 120 mg/dL. Atorvastatin is a medication used to lower LDL cholesterol levels. A decrease in LDL levels indicates the effectiveness of the treatment in reducing the risk of cardiovascular events. BUN, blood glucose, and urine specific gravity are not directly related to the effectiveness of atorvastatin in lowering cholesterol levels. BUN reflects kidney function, blood glucose monitors glucose levels, and urine specific gravity indicates hydration status. Therefore, D is the best indicator of treatment effectiveness.
A nurse is caring for a 4-year-old child following an orthopedic procedure. When assessing the child for pain, which of the following pain scales should the nurse use?
- A. FACES
- B. Numeric
- C. CRIES
- D. Word graphic
Correct Answer: A
Rationale: The correct answer is A: FACES. This is because the FACES pain scale is specifically designed for children aged 3 and older, making it appropriate for a 4-year-old. The scale uses facial expressions to help the child express their level of pain, which is easier for young children to understand and communicate. The other options are not suitable for a 4-year-old child: Numeric scales may be too abstract, CRIES scale is used for infants, and Word Graphic scale may be too complex for a young child to comprehend. Using the FACES pain scale will allow the nurse to accurately assess and manage the child's pain effectively.
A nurse is teaching a client about oral contraceptive. Which of the following information should the nurse include in the teaching?
- A. Abdominal pain is an expected adverse effect of oral contraceptives
- B. It can take up to 1 year to become pregnant after stopping an oral contraceptive
- C. Some herbal supplements can decrease the effectiveness of an oral contraceptive
- D. A pelvic examination is needed prior to starting an oral contraceptive
Correct Answer: C
Rationale: The correct answer is C: Some herbal supplements can decrease the effectiveness of an oral contraceptive. The nurse should include this information in the teaching to ensure the client understands potential interactions. Herbal supplements like St. John's Wort can reduce the effectiveness of oral contraceptives by increasing their metabolism. This can lead to contraceptive failure and unintended pregnancy. Option A is incorrect because abdominal pain is not an expected adverse effect of oral contraceptives. Option B is incorrect as fertility typically returns quickly after stopping oral contraceptives, not taking up to a year. Option D is incorrect as a pelvic examination is not always necessary before starting oral contraceptives.
A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?
- A. Apply firm pressure to the injection site following administration
- B. Administer the medication into the client's muscle
- C. Expel the air bubble from the syringe prior to injection
- D. Insert the syringe needle halfway into the client's skin
Correct Answer: A
Rationale: Correct Answer: A: Apply firm pressure to the injection site following administration.
Rationale: Applying firm pressure to the injection site following administration of enoxaparin helps minimize the risk of bleeding, as enoxaparin is an anticoagulant medication. This pressure promotes clot formation and reduces the likelihood of bruising or hematoma formation at the injection site.
Summary of other choices:
B: Administer the medication into the client's muscle - Incorrect. Enoxaparin is a subcutaneous medication, not meant for intramuscular administration.
C: Expel the air bubble from the syringe prior to injection - Good practice but not directly related to the administration of enoxaparin.
D: Insert the syringe needle halfway into the client's skin - Incorrect. The needle should be fully inserted for proper subcutaneous injection.