Nokea
A nurse is caring for a client who reports difficulty breathing during the administration of an intermittent IV bolus of nafcillin. After stopping the infusion and notifying the provider, the nurse should anticipate a prescription for which of the following medications?
- A. Deferoxamine
- B. Vitamin K
- C. Epinephrine
- D. Prednisone
Correct Answer: C
Rationale: The correct answer is C: Epinephrine. This medication is indicated for the treatment of anaphylaxis, a severe allergic reaction that can cause difficulty breathing. Given the client's symptoms of difficulty breathing during the IV bolus administration of nafcillin, an allergic reaction is a likely cause. Epinephrine is the first-line treatment for anaphylaxis as it works quickly to constrict blood vessels, relax smooth muscles in the airways, and improve breathing. Deferoxamine (A) is used for iron toxicity, Vitamin K (B) for coagulation disorders, and Prednisone (D) for inflammation, none of which are indicated for this client's symptoms.
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History and Physical
Medication Administration Record
Vital Signs
1630:
Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields. Diffuse, raised rash present on trunk. Abdomen soft. nontender.
A nurse in the emergency department is assisting in the care of a client.
Click to highlight the findings that require immediate follow-up. To deselect a finding click on the finding again.
Nurses Notes
1630:
Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields, Diffuse, raised rash present on trunk. Abdomen soft, nontender
Vital Signs
1630:
Temperature 38.3°C (101°F)
Heart rate 110/min
Respiratory rate 30/min
Blood pressure 90/55 mmHg
Oxygen saturation 91% on room air
Click to highlight the findings that require immediate follow-up.
- A. Client is short of breath
- B. Intercostal retractions visible
- C. Wheezing auscultated throughout lung fields
- D. Diffuse, raised rash present on trunk
- E. Respiratory rate 30/min
- F. Blood pressure 90/55 mmHg
- G. Oxygen saturation 91% on room air
Correct Answer: A,B,C,D,E,F,G
Rationale: [ , , , , , , ]
A nurse is collecting data from a client who has a new prescription for nitrofurantoin to treat a urinary tract infection. The nurse should monitor the client for which of the following adverse effects?
- A. Tinnitus
- B. Abdominal cramping
- C. Stevens-Johnson syndrome
- D. Insomnia
Correct Answer: C
Rationale: The correct answer is C: Stevens-Johnson syndrome. Nitrofurantoin can cause serious adverse effects like Stevens-Johnson syndrome, which is a severe skin reaction. This syndrome presents with flu-like symptoms, followed by a painful rash that can lead to skin peeling and blistering. It is important for the nurse to monitor the client for any signs of skin rash, especially if it is accompanied by mucous membrane involvement. Tinnitus (choice A) and abdominal cramping (choice B) are not commonly associated with nitrofurantoin. Insomnia (choice D) is also not a common adverse effect of this medication.
A nurse is reinforcing teaching with a client who has a new prescription for alendronate for the treatment of osteoporosis. The nurse should instruct the client to monitor for which of the following adverse effects?
- A. Anorexia
- B. Jaw pain
- C. Insomnia
- D. Bruising
Correct Answer: B
Rationale: The correct answer is B: Jaw pain. Alendronate, a bisphosphonate medication used to treat osteoporosis, can cause a rare but serious side effect called osteonecrosis of the jaw (ONJ), characterized by jaw pain, swelling, and possible infection. It is essential for the nurse to instruct the client to monitor for any signs of jaw pain to promptly report to their healthcare provider. Anorexia (A), insomnia (C), and bruising (D) are not typically associated with alendronate use for osteoporosis and would not be common adverse effects that the client needs to monitor for.
A nurse is preparing to administer medications to a client through an enteral feeding tube. Which of the following interventions is appropriate?
- A. Add the medications to the enteral feeding bag.
- B. Check for gastric residual 15 min after administering the medications
- C. Keep the client's head elevated 15° while administering the medications.
- D. Flush the tube with 30 ml of water between each medication
Correct Answer: D
Rationale: The correct answer is D: Flush the tube with 30 ml of water between each medication. Flushing the tube with water between medications helps prevent clogging and ensures proper medication administration. It also helps prevent interactions between different medications. Adding medications to the feeding bag (choice A) may cause drug interactions or alter the efficacy of the medications. Checking for gastric residual 15 min after administering medications (choice B) is not necessary for enteral tube medication administration. Keeping the client's head elevated 15° (choice C) is important during feeding, but not specifically for medication administration.
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.