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A nurse is assessing a client who is experiencing an anaphylactic reaction to an antibiotic. Which of the following manifestations of anaphylaxis should the nurse expect?
- A. Hypertonic reflexes
- B. Increase in systolic blood pressure
- C. Angioedema
- D. Urinary retention
Correct Answer: C
Rationale: The correct answer is C: Angioedema. Anaphylaxis is a severe allergic reaction that can cause swelling of the deep layers of the skin, including the subcutaneous tissue and mucosa. Angioedema is a common manifestation of anaphylaxis, typically involving swelling of the lips, face, and throat, which can lead to airway obstruction.
A: Hypertonic reflexes - This is not a typical manifestation of an anaphylactic reaction. Anaphylaxis is more commonly associated with hypotension.
B: Increase in systolic blood pressure - Anaphylaxis typically causes a rapid decrease in blood pressure, leading to hypotension rather than hypertension.
D: Urinary retention - This is not a common manifestation of an anaphylactic reaction. Anaphylaxis is more likely to cause symptoms such as urticaria, bronchospasm, and gastrointestinal symptoms.
Therefore, the correct answer is C, as angioed
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A nurse is assessing a client who has ovarian cancer and is receiving paclitaxel. Which of the following findings is the priority for the nurse to report to the provider?
- A. Alopecia
- B. Muscle pain
- C. Nausea
- D. Bradycardia
Correct Answer: D
Rationale: The correct answer is D: Bradycardia. Bradycardia is a potentially serious side effect of paclitaxel that can lead to life-threatening complications like decreased perfusion. The nurse should report this immediately to the provider for prompt intervention. Alopecia, muscle pain, and nausea are common side effects of paclitaxel but are not immediate priorities compared to bradycardia. Reporting bradycardia promptly can help prevent further complications and ensure the client's safety.
A nurse is caring for a client who has congestive heart failure and is taking captopril. Which of the following laboratory values should the nurse report to the provider as a potential adverse effect of captopril?
- A. Absolute neutrophil count (ANC) 4.000/ mm^3
- B. Brain natriuretic peptide (BNP) 90 ng/L
- C. Sodium 140 mEq/l
- D. Creatinine 2 mg/dl
Correct Answer: D
Rationale: The correct answer is D: Creatinine 2 mg/dl. Captopril, an ACE inhibitor, can cause renal impairment as a potential adverse effect due to its effects on the renin-angiotensin-aldosterone system. Creatinine is a waste product that is filtered by the kidneys, and an increase in creatinine levels indicates impaired renal function. Therefore, a creatinine level of 2 mg/dl should be reported to the provider when caring for a client taking captopril.
Choices A, B, and C are within normal ranges and not directly related to captopril's adverse effects. Choice A is related to the immune system, while choice B is a marker for heart failure. Choice C is a measure of electrolyte balance. These values would not typically be affected by captopril.
In summary, the nurse should report an elevated creatinine level as a potential adverse effect of captopril, as it indicates renal impairment, while the other laboratory
A nurse is caring for a client who is receiving long-term treatment with oral doses of prednisone. For which of the following adverse effects should the nurse monitor?
- A. Hypoglycemia
- B. Hyperreflexia
- C. Osteoporosis
- D. Inflammatory bowel disease
Correct Answer: C
Rationale: The correct answer is C: Osteoporosis. Prednisone is a corticosteroid medication that can lead to bone loss and increase the risk of osteoporosis with long-term use. The rationale: Prednisone inhibits calcium absorption and bone formation, resulting in decreased bone density. Monitoring for osteoporosis is crucial to prevent fractures. Hypoglycemia (A) is not a common adverse effect of prednisone but hyperglycemia is. Hyperreflexia (B) is not typically associated with prednisone. Inflammatory bowel disease (D) is not an adverse effect of prednisone, as it is actually used to treat inflammatory conditions.
A nurse is preparing to administer morphine 8 mg IV intermittent bolus to a client. The amount available is morphine 10 mg/mL. How many mL should the nurse administer?
- A. 0.8 mL
Correct Answer: A
Rationale: The correct answer is A: 0.8 mL. To calculate the amount of morphine to administer, divide the desired dose (8 mg) by the concentration (10 mg/mL). 8 mg / 10 mg/mL = 0.8 mL. The other choices are incorrect because they do not reflect the correct calculation based on the given information. A nurse must accurately calculate medication dosages to ensure patient safety.
A nurse is planning care for a client who has a new prescription to receive a continuous infusion of total parenteral nutrition (TPN) Which of the following interventions should the nurse implement?
- A. Change the TPN infusion tubing once every 3 days
- B. Check the client's blood glucose level regularly
- C. Insert the peripheral IV catheter for administration
- D. Monitor the client's weight every 3 days
Correct Answer: B
Rationale: The correct answer is B: Check the client's blood glucose level regularly. This is essential as TPN is a high-calorie, nutrient-dense solution that can increase the risk of hyperglycemia. Monitoring blood glucose levels helps the nurse assess the client's response to TPN and adjust the infusion rate accordingly to prevent complications.
Option A is incorrect because changing the TPN infusion tubing once every 3 days is not a priority in this situation. Option C is incorrect as TPN should be administered through a central venous catheter, not a peripheral IV catheter. Option D is incorrect as monitoring the client's weight every 3 days is not as crucial as monitoring blood glucose levels when on TPN.