Nokea
A nurse is caring for a client who is receiving methyldopa hydrochloride (Aldomet) intravenously. Which of the following assessment findings would indicate to the nurse that the client may be having an adverse reaction to the medication?
- A. Headache
- B. Mood changes
- C. Hyperkalemia
- D. Palpitations
Correct Answer: B
Rationale: Mood changes. The nurse should assess the client for alterations in mental status such as mood changes. These symptoms should be reported promptly.
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The nurse administers 18 units of Humulin N, an intermediate-acting insulin, at 1630. Which priority intervention should the nurse implement?
- A. Monitor the client's hemoglobin A1c.
- B. Make sure the client eats the evening meal.
- C. Check the a.c. blood glucometer reading.
- D. Ensure the client eats a snack.
Correct Answer: B
Rationale: Humulin N peaks in 4–12 hours; evening meal prevents hypoglycemia during peak action. A1c, a.c. checks, or snacks are less immediate.
An adult is receiving Gantrisin 1 g PO qid for a urinary tract infection. Which statement that she makes indicates a need for more teaching?
- A. If I get a rash, I will apply calamine lotion.
- B. I will take my pills with a full glass of water.
- C. I will take all the pills even if I feel better.
- D. I will stay out of the sun while I am taking the pills.
Correct Answer: A
Rationale: A rash may indicate an adverse reaction to Gantrisin, requiring physician consultation, not self-treatment with calamine lotion.
The client is admitted to the burn unit and prescribed pantoprazole (Protonix), a proton pump inhibitor (PPI). Which statement best supports the scientific rationale for administering this medication to a client with a severe burn?
- A. This medication will help prevent a stress ulcer.
- B. This medication will help prevent systemic infections.
- C. This medication will provide continuous vasoconstriction.
- D. This medication will stimulate new skin growth.
Correct Answer: A
Rationale: Severe burns increase stress ulcer risk due to gastric acid hypersecretion; PPIs like pantoprazole prevent this. Infection, vasoconstriction, or skin growth are unrelated.
Which observation, if reported by a client, is most suggestive of an adverse reaction to gentamicin?
- A. A WBC of 8000
- B. Ringing in the ears
- C. Itching
- D. Nasal stuffiness
Correct Answer: B
Rationale: Gentamicin is ototoxic. Ringing in the ears suggests possible damage to the eighth cranial nerve, the auditory nerve. A WBC of 8000 is normal.
The client received Narcan, a narcotic antagonist, following a colonoscopy. Which action by the nurse has the highest priority?
- A. Document the occurrence in the nurse's notes.
- B. Prepare to administer narcotic medication IV.
- C. Administer oxygen via nasal cannula.
- D. Assess the client every 15 to 30 minutes.
Correct Answer: D
Rationale: Narcan reverses opioids but has a short half-life; frequent assessment (15–30 min) monitors for re-sedation or respiratory depression, the priority.