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A nurse is caring for a client who has a new prescription for fluoxetine. Which of the following adverse effects should the nurse monitor for?
- A. Weight loss
- B. Bradycardia
- C. Hypotension
- D. Insomnia
Correct Answer: D
Rationale: Fluoxetine, an SSRI, can cause insomnia due to its stimulatory effect on the central nervous system.
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A nurse is reinforcing teaching with a client who is scheduled for a urodynamic study. Which of the following instructions should the nurse include?
- A. Fast for 8 hours before the study.
- B. Avoid urinating before the study.
- C. Expect general anesthesia.
- D. Remove all jewelry before the study.
Correct Answer: B
Rationale: Avoiding urination before a urodynamic study ensures the bladder is full, allowing accurate assessment of bladder function.
A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)
- A. Pale-colored toes
- B. Decreased skin turgor
- C. Pain relieved by analgesia
- D. Diminished capillary refill
- E. Sensation of tingling
Correct Answer: A,D,E
Rationale: Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle damage.
A nurse is caring for a client who has a new diagnosis of esophageal varices. Which of the following findings should the nurse expect?
- A. Hematemesis
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Hematemesis, vomiting blood, is a common symptom of esophageal varices due to portal hypertension.
A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?
- A. Instruct the client to hold the drainage bag at waist height when ambulating.
- B. Coil the tubing on the bed above the collection bag.
- C. Collect a sterile specimen from the urinary drainage bag.
- D. Secure the tubing with adhesive tape to the lower abdomen.
Correct Answer: D
Rationale: Securing the tubing with adhesive tape to the lower abdomen is correct. For male clients, securing the catheter to the lower abdomen prevents urethral trauma and tension. For female clients, the catheter is typically secured to the inner thigh to minimize movement and irritation.
A nurse is reinforcing teaching with a client who has a new prescription for lisinopril. Which of the following adverse effects should the nurse include?
- A. Dry cough
- B. Weight gain
- C. Tinnitus
- D. Hypoglycemia
Correct Answer: A
Rationale: Lisinopril, an ACE inhibitor, can cause a dry cough due to increased bradykinin levels, a common side effect.