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A nurse is caring for a client receiving patient-controlled analgesia (PCA). Which of the following interventions should the nurse take while caring for this client?
- A. Advise the client to use the pump sparingly to prevent addiction
- B. Encourage the client to use the PCA before dressing changes
- C. Encourage the client's family to administer PCA while the client is sleeping
- D. Increase the client's 4-hour limit as needed
Correct Answer: B
Rationale: The correct answer is B because encouraging the client to use the PCA before dressing changes helps in managing pain proactively. Choice A is incorrect as PCA is a safe method of pain control when used appropriately, and the nurse should not suggest using it sparingly. Choice C is incorrect as only the client should operate the PCA to ensure they are in control of their pain management. Choice D is incorrect as changing the PCA limit without proper assessment and orders from the healthcare provider can lead to adverse effects.
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A nurse is preparing to administer furosemide to a client. Which of the following findings indicates the client may be at risk for an adverse effect of the medication?
- A. Hypertension
- B. Hypokalemia
- C. Increased urine output
- D. Hyperglycemia
Correct Answer: B
Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can cause potassium depletion, leading to hypokalemia, which is a common adverse effect. Hypokalemia can result in serious complications like cardiac arrhythmias. Choices A, C, and D are not directly associated with the adverse effects of furosemide. Hypertension is a condition that furosemide is often used to treat, increased urine output is an expected effect of furosemide, and hyperglycemia is not a typical adverse effect of this medication.
A nurse is caring for a client receiving theophylline for chronic obstructive pulmonary disease (COPD). Which of the following client findings indicates the need for immediate intervention?
- A. Productive cough
- B. Drowsiness
- C. Vomiting
- D. Polyuria
Correct Answer: D
Rationale: Polyuria is a sign of theophylline toxicity and requires immediate intervention. Theophylline toxicity can lead to serious complications, and polyuria is a concerning symptom that indicates the need for urgent medical attention. Productive cough, drowsiness, and vomiting are common side effects of theophylline but are not typically indicative of immediate life-threatening issues like polyuria in the context of theophylline toxicity.
A nurse is caring for a client newly prescribed doxazosin mesylate. Which of the following instructions should the nurse include in client education regarding taking the first dose of this medication?
- A. Change positions slowly and lie down if dizziness occurs
- B. There is no need to avoid normal activities
- C. Avoid dairy products while taking this medication
- D. Do not eat green leafy vegetables
Correct Answer: A
Rationale: Corrected Rationale: First-dose orthostatic hypotension can occur with doxazosin. The nurse should advise the client to change positions slowly and lie down if dizziness occurs. Choice B is incorrect because it does not address the potential side effect of dizziness. Choice C and D are also incorrect as there is no specific dietary restriction related to doxazosin mesylate.
A nurse is caring for a client with hypothyroidism. Which of the following findings indicates that the client is experiencing an adverse effect from the prescribed levothyroxine?
- A. Tachycardia
- B. Bradycardia
- C. Weight loss
- D. Increased appetite
Correct Answer: A
Rationale: Tachycardia is the correct answer as it is an adverse effect of levothyroxine. Levothyroxine is a medication used to treat hypothyroidism by supplementing the body with thyroid hormone. Tachycardia, or a fast heart rate, can indicate an overdosage or increased sensitivity to levothyroxine. Bradycardia, slow heart rate, weight loss, and increased appetite are not typically associated with adverse effects of levothyroxine. Bradycardia may actually be a symptom of untreated hypothyroidism.
A healthcare provider is preparing to administer a measles, mumps, and rubella (MMR) vaccine to an adult client. Which of the following is a contraindication to this vaccine?
- A. The possibility of pregnancy within 4 weeks
- B. Client allergy to strawberries
- C. Client history of genital herpes
- D. The possibility of overseas travel in the next month
Correct Answer: A
Rationale: The correct answer is A. Pregnancy or the possibility of pregnancy within 4 weeks is a contraindication for receiving the MMR vaccine. Choice B, client allergy to strawberries, is not a contraindication to the MMR vaccine. Choice C, client history of genital herpes, is not a contraindication for the MMR vaccine. Choice D, the possibility of overseas travel in the next month, is not a contraindication to the MMR vaccine.