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A nurse is caring for a client who has a prescription for ceftriaxone. The nurse should monitor the client for which of the following adverse effects?
- A. Concentrated urine
- B. Maculopapular rash
- C. Constipation
- D. Pitting edema
Correct Answer: B
Rationale: The correct answer is B: Maculopapular rash. Ceftriaxone is a cephalosporin antibiotic known to cause hypersensitivity reactions, including skin rashes like maculopapular rash. This type of rash is common with antibiotic use and may indicate an allergic reaction. Monitoring for this adverse effect is crucial to assess the client's response to the medication.
A: Concentrated urine is not a typical adverse effect of ceftriaxone.
C: Constipation is not a common adverse effect associated with ceftriaxone.
D: Pitting edema is not a recognized adverse effect of ceftriaxone.
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A nurse is caring for a client who had abdominal surgery. The client is grimacing and has a respiratory rate of 24/min. Which of the following actions should the nurse take first?
- A. Offer the client a cold compress.
- B. Play music in the client's room as a distraction.
- C. Check the client's current level of pain.
- D. Assist the client to reposition in bed.
Correct Answer: C
Rationale: The correct answer is C: Check the client's current level of pain. The nurse should assess the client's pain first to determine the cause of grimacing and tachypnea. Pain after abdominal surgery can indicate complications like infection or inadequate pain management. Addressing pain is a priority to ensure the client's comfort and prevent further complications. Options A, B, and D do not address the underlying issue of pain and are therefore not the most appropriate actions. Offering a cold compress or playing music may provide temporary relief but do not address the root cause. Repositioning may help with comfort but should come after assessing and addressing the pain.
A nurse is preparing to administer acetaminophen 10 mg/kg PO every 6 hr to a toddler who weighs 26.4 lb. Available is acetaminophen 80 mg/0.8 mL liquid. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 1.2
Correct Answer: A
Rationale: To calculate the correct dose, first convert the toddler's weight from pounds to kilograms: 26.4 lb / 2.2 = 12 kg. Then calculate the dose: 10 mg/kg * 12 kg = 120 mg per dose. Next, determine how many mL of the liquid acetaminophen contain 120 mg: 80 mg/0.8 mL = 120 mg/X mL. Cross multiply to find X = 1.2 mL. Therefore, the correct answer is A: 1.2 mL. Other choices are incorrect as they do not align with the calculated dose based on the toddler's weight and the concentration of the liquid form of acetaminophen available.
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The nurse should identify which of the following findings as an indication of a febrile nonhemolytic reaction?
- A. Dyspnea
- B. Urticaria
- C. Chills
- D. Vomiting
Correct Answer: C
Rationale: The correct answer is C: Chills. A febrile nonhemolytic reaction during a blood transfusion is characterized by the sudden onset of chills and fever, usually within the first 15 minutes to 2 hours of the transfusion. This reaction is caused by the recipient's antibodies reacting to donor leukocytes. Dyspnea (A), urticaria (B), and vomiting (D) are more indicative of other transfusion reactions such as an allergic reaction, hemolytic reaction, or bacterial contamination, respectively.
Nurses’ notes
Vital Signs
Medication Administration Record
Client reports tightness in the chest that radiates to the left arm. States pain as 7 on a scale of 0 to 10. Client is diaphoretic and short of breath.
Which of the following instructions should the nurse include when reinforcing teaching to the client about their medication? Select all that apply.
- A. Lie down with feet elevated if dizziness occurs while taking this medication.
- B. Apply the patch daily to a hairless area of the skin.
- C. The medication will be effective 30 to 45 min following application.
- D. Remove the patch 12 to 14 hr following application.
- E. Remove the patch if you experience a headache.
- F. Place the patch on the same area every day.
Correct Answer: A,B,D
Rationale: Correct answer: A, B, D
Rationale:
A: Instructing the client to lie down with feet elevated if dizziness occurs is important as it can prevent falls and injury.
B: Applying the patch to a hairless area of the skin ensures proper drug absorption and effectiveness.
D: Removing the patch after 12 to 14 hours prevents skin irritation and ensures the medication is not being overexposed.
Incorrect answer explanations:
C: The time frame given for medication effectiveness is inaccurate and may lead to confusion.
E: Removing the patch if experiencing a headache is not a standard instruction and may interfere with the medication's intended purpose.
F: Placing the patch on the same area daily can lead to skin irritation or decreased drug absorption due to buildup.
A nurse is reinforcing teaching with a client who has a new prescription for nitroglycerin transdermal patches to treat angina. The nurse should inform the client that which of the following manifestations is an adverse effect of the medication?
- A. Headache
- B. Polyuria
- C. Ringing in the ears
- D. Increased blood pressure
Correct Answer: A
Rationale: The correct answer is A: Headache. Nitroglycerin transdermal patches can cause headaches as an adverse effect due to vasodilation leading to increased blood flow to the brain. This is a common side effect that may occur in patients using nitroglycerin. Polyuria (B) and ringing in the ears (C) are not common side effects of nitroglycerin. Increased blood pressure (D) is not an adverse effect of nitroglycerin; in fact, nitroglycerin decreases blood pressure by dilating blood vessels.