Nokea
A nurse is caring for a patient who has a new prescription for enalapril. Which of the following adverse effects should the nurse monitor for? Which adverse effect should the nurse monitor for enalapril?
- A. Dry cough
- B. Weight loss
- C. Tinnitus
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Dry cough. Enalapril is an ACE inhibitor commonly associated with a side effect of a persistent dry cough due to increased bradykinin levels. The nurse should monitor the patient for this adverse effect as it can indicate drug intolerance. Choices B, C, and D are incorrect as weight loss, tinnitus, and hypoglycemia are not commonly associated with enalapril use. Weight gain may be more common due to fluid retention, tinnitus is not a known side effect, and hypoglycemia is not typically linked with enalapril.
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History & Physical (0700hrs)
Date: 06/28/0X
• Client presented to the clinic reporting pelvic pain, dysmenorrhea, dyspareunia, and pain with defecation.
• Vaginal examination reveals fixed, palpable nodules with a retroverted uterus.
• Imaging reveals endometrial lesions on the ovaries, uterosacral ligaments, and round ligaments.
• Endometriosis diagnosed.
Provider's Prescriptions (0700hrs)
• Nafarelin 200 mcg: 1 spray intranasally every morning and 1 spray in the opposite nostril every evening.
Nurse's Notes (0700hrs)
• Client reports adherence to nafarelin regimen without missing doses.
• Client verbalizes irritation in the nasal mucosa.
• Reports feeling better overall with decreased dyspareunia.
• Notes decreased pain during bowel movements.
• Reports decreased pelvic pain and the absence of menstruation last month.
• Mentions experiencing headaches, increased acne, and reduced sex drive since starting treatment.
• Client observes a decrease in breast size.
Scenario:
A nurse is caring for a 32-year-old female client who was recently diagnosed with endometriosis. The client is in the clinic for a follow-up visit after beginning nafarelin treatment.
Setting: Clinic
Which of the following manifestations reported by the client should the nurse identify as a therapeutic effect of the nafarelin? (Select all that apply.)
- A. CNS manifestations
- B. Pain level during sexual intercourse
- C. Nasal mucosa changes
- D. Breast changes
- E. Missed previous month's menstrual cycle
- F. Dermatological manifestations
Correct Answer: B,E
Rationale: The correct answers are B and E. Nafarelin is a gonadotropin-releasing hormone (GnRH) agonist used to treat endometriosis by suppressing estrogen production, thereby reducing symptoms like pain during intercourse (choice B) and causing missed menstrual cycles (choice E). These are therapeutic effects. Choices A, C, D, and F are incorrect because CNS manifestations, nasal mucosa changes, breast changes, and dermatological manifestations are not commonly reported therapeutic effects of nafarelin. Thus, options A, C, D, and F can be ruled out.
A nurse is caring for a patient who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider? Which finding should the nurse report during bladder irrigation?
- A. Urine output of 200 mL/hr
- B. Pink-tinged urine
- C. Clots in the drainage bag
- D. Bladder spasms
Correct Answer: C
Rationale: The correct answer is C: Clots in the drainage bag. This finding should be reported to the provider because it may indicate bleeding or clot formation, which can obstruct the catheter and impair the irrigation process. Clots can also increase the risk of urinary retention or infection. Reporting this finding promptly allows the provider to assess the patient's condition and take appropriate interventions to prevent complications.
Incorrect choices:
A: Urine output of 200 mL/hr is within the expected range for continuous bladder irrigation and does not necessarily indicate a problem.
B: Pink-tinged urine is a common finding following prostate surgery and is expected during bladder irrigation.
D: Bladder spasms are common after prostate surgery and can be managed with appropriate medications.
E, F, G: These choices are not provided, but they would be incorrect as they are not related to complications of bladder irrigation post-prostate surgery.
A nurse is caring for a patient who is receiving mechanical ventilation. Which of the following actions should the nurse take to prevent ventilator-associated pneumonia? Which action prevents ventilator-associated pneumonia?
- A. Perform oral care every 12 hours.
- B. Keep the head of the bed elevated to 30-45 degrees.
- C. Administer antibiotics prophylactically.
- D. Change the ventilator circuit daily.
Correct Answer: B
Rationale: The correct answer is B: Keep the head of the bed elevated to 30-45 degrees. Elevating the head of the bed helps prevent aspiration, which is a significant risk factor for ventilator-associated pneumonia. This position promotes proper lung expansion and drainage of secretions, reducing the likelihood of bacterial growth in the lungs. Performing oral care every 12 hours (A) is important for oral hygiene but does not directly prevent ventilator-associated pneumonia. Administering antibiotics prophylactically (C) can lead to antibiotic resistance and is not recommended routinely. Changing the ventilator circuit daily (D) is important for infection control but does not directly prevent ventilator-associated pneumonia.
A nurse is educating a patient with diabetes who has been prescribed insulin glargine. What information should the nurse provide about this type of insulin?,What information should be provided about insulin glargine?
- A. Insulin glargine lasts for 3 to 6 hours.
- B. Insulin glargine lasts for 18 to 24 hours.
- C. Insulin glargine lasts for 16 to 24 hours.
- D. Insulin glargine lasts for 6 to 10 hours.
Correct Answer: B,C
Rationale: The correct answer is B and C. Insulin glargine is a long-acting insulin that provides a basal level of insulin over an extended period. Option B states that it lasts for 18 to 24 hours, which is accurate as it mimics the body's natural basal insulin secretion. Option C also mentions 16 to 24 hours, which is within the range of the duration of action for insulin glargine. Option A stating 3 to 6 hours is incorrect as it does not reflect the long-acting nature of insulin glargine. Option D stating 6 to 10 hours is also incorrect as it underestimates the duration. It is important for the nurse to emphasize the prolonged action of insulin glargine to ensure proper understanding and management by the patient.
A nurse is conducting a patient's history and physical examination. Which information should the nurse consider as subjective data? Which information is subjective data?
- A. Petechiae
- B. Nausea
- C. Cyanosis
- D. Fever
Correct Answer: B
Rationale: Subjective data is information provided by the patient based on their feelings, perceptions, or beliefs. Nausea falls under this category as it is a symptom that the patient experiences and reports subjectively. Petechiae, cyanosis, and fever are objective data as they can be observed or measured directly. Petechiae are small red or purple spots on the skin, cyanosis is a bluish discoloration of the skin due to lack of oxygen, and fever is an elevated body temperature, all of which can be confirmed through visual inspection or measurement. Therefore, choice B, nausea, is the correct answer as it relies on the patient's subjective experience.