Nokea
A nurse is caring for a client who is receiving filgrastim. The nurse should monitor the client for which of the following adverse effects?
- A. Hypertension
- B. Fluid retention
- C. Bone pain
- D. Hypokalemia
Correct Answer: C
Rationale: The correct answer is C: Bone pain. Filgrastim is a medication that stimulates the production of white blood cells. Bone pain is a common adverse effect because it indicates the bone marrow is producing more cells. Monitoring for bone pain is crucial to assess the effectiveness of the medication. Hypertension (A) and fluid retention (B) are not typically associated with filgrastim. Hypokalemia (D) is not a common adverse effect of filgrastim.
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A nurse is preparing to administer erythromycin PO to a client who has an infection. The nurse checks the client's medical record and notes that the client has a severe allergy to penicillin. Which of the following actions should the nurse take?
- A. Premedicate the client with diphenhydramine.
- B. Request a different route of administration from the provider.
- C. Administer the medication to the client.
- D. Request a different medication from the provider.
Correct Answer: C
Rationale: Rationale:
The correct action is to administer the medication to the client (Choice C) because erythromycin is not related to penicillin, and having a severe allergy to penicillin does not contraindicate the use of erythromycin. Premedicating with diphenhydramine (Choice A) is not necessary as there is no cross-reactivity between erythromycin and penicillin. Requesting a different route of administration (Choice B) is unnecessary as the oral route is appropriate for erythromycin. Requesting a different medication (Choice D) is not required, as erythromycin is safe to use in a client with a penicillin allergy.
A nurse is caring for a client who is receiving heparin therapy. If the client requires a reversal of the effects of heparin, which of the following medications should the nurse expect the provider to prescribe?
- A. Atropine
- B. Vitamin K
- C. Vitamin B12
- D. Protamine
Correct Answer: D
Rationale: The correct answer is D: Protamine. Protamine is the antidote for heparin as it works by forming a complex with heparin, neutralizing its anticoagulant effects. Atropine (A) is used for bradycardia, not for heparin reversal. Vitamin K (B) is used to reverse the effects of warfarin, a different anticoagulant. Vitamin B12 (C) is not used for heparin reversal. Therefore, the correct choice is Protamine (D) for reversing heparin's effects.
A nurse is collecting data from a client who is taking dimenhydrinate to treat motion sickness. Which of the following findings is an adverse effect of this medication?
- A. Drowsiness
- B. Hypertension
- C. Polyuria
- D. Dependent edema
Correct Answer: A
Rationale: The correct answer is A: Drowsiness. Dimenhydrinate is an antihistamine commonly used for motion sickness, which can cause drowsiness as a common adverse effect due to its sedative properties. This is because it can cross the blood-brain barrier and affect the central nervous system, leading to drowsiness. The other options are incorrect because hypertension (B) is not a known adverse effect of dimenhydrinate, polyuria (C) is excessive urination, which is not typically associated with this medication, and dependent edema (D) is swelling due to fluid buildup, which is also not commonly caused by dimenhydrinate. Therefore, the correct adverse effect to expect with dimenhydrinate use is drowsiness.
Vital Signs
History and Physical
Assessment
Laboratory Results
Provider Prescriptions
Yesterday:
Temperature 37.4° C (99.3° F)
Heart rate 92/min
Respiratory rate 18/min
Blood pressure 130/82 mm Hg
Oxygen saturation 97% on room air
Today:
Temperature 38.9° C (102° F) Heart rate 110/min
Respiratory rate 18/min
Blood pressure 138/88 mm Hg
Oxygen saturation 96% on room air
The nurse has reviewed the client's electronic medical record (EMR). Which of the following findings should the nurse recommend withholding the ceftriaxone? Select all that apply.
- A. Breastfeeding
- B. Client allergy
- C. Gentamycin prescription
- D. Hematocrit
- E. Hemoglobin
Correct Answer: B,C
Rationale: The correct answers are B and C.
B: Withholding ceftriaxone is recommended if the client has an allergy to it to prevent an allergic reaction.
C: Gentamicin can interact with ceftriaxone, leading to potential adverse effects.
Incorrect choices:
A: Breastfeeding is not a contraindication for ceftriaxone use.
D and E: Hematocrit and hemoglobin levels are not directly related to the administration of ceftriaxone.
A nurse is collecting data from a client before administering a hepatitis B immunization. The nurse should withhold the immunization if the client is allergic to which of the following substances?
- A. Baker's yeast
- B. Nuts
- C. Wheat
- D. Egg yolk
Correct Answer: A
Rationale: The correct answer is A: Baker's yeast. Hepatitis B vaccines are produced using baker's yeast, specifically Saccharomyces cerevisiae. If a client is allergic to baker's yeast, there is a risk of an allergic reaction to the vaccine. Nuts (B), wheat (C), and egg yolk (D) are not ingredients used in the hepatitis B vaccine production, so allergies to these substances would not necessitate withholding the immunization.