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A nurse is caring for a patient who has benign prostatic hypertrophy and is taking tamsulosin. Which of the following adverse effects should the nurse monitor for? Which adverse effect of tamsulosin should the nurse monitor?
- A. Diarrhea
- B. Orthostatic hypotension
- C. Weight loss
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Orthostatic hypotension. Tamsulosin, an alpha-blocker, can cause relaxation of smooth muscle in blood vessels leading to a drop in blood pressure upon standing, resulting in orthostatic hypotension. The nurse should monitor the patient for symptoms such as dizziness, lightheadedness, or fainting when changing positions. Diarrhea (choice A), weight loss (choice C), and tinnitus (choice D) are not commonly associated with tamsulosin use. It is crucial for the nurse to understand the pharmacological effects of tamsulosin to provide safe and effective care for the patient.
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A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following patients should the nurse identify as requiring airborne precautions? Which patient requires airborne precautions?
- A. A patient who has streptococcal pharyngitis
- B. A patient who has scabies
- C. A patient who has measles
- D. A patient who has pertussis
Correct Answer: C
Rationale: The correct answer is C: A patient who has measles. Measles is a highly contagious airborne disease spread through respiratory droplets. Airborne precautions are necessary to prevent transmission. Streptococcal pharyngitis (A) is spread through direct contact or respiratory droplets, not airborne. Scabies (B) is transmitted through skin-to-skin contact, not airborne. Pertussis (D) is spread through respiratory droplets, but not as easily as measles, so airborne precautions are not typically required.
A nurse is preparing to infuse ampicillin and gentamicin sulfate intravenously. Which resource should the nurse first consult for information on medication compatibility? Which resource should the nurse consult for compatibility?
- A. Hospital pharmacist
- B. Health care provider
- C. Medication sales representative
- D. Nurse manager
Correct Answer: A
Rationale: The correct answer is A: Hospital pharmacist. The pharmacist is the most appropriate resource for medication compatibility information because they have the expertise in drug interactions, contraindications, and compatibility issues. Pharmacists can provide detailed information on how ampicillin and gentamicin sulfate interact when given together intravenously. Consulting a pharmacist ensures patient safety by preventing potential adverse drug reactions. Health care providers may not have detailed knowledge of medication compatibility. Medication sales representatives may have biased information and limited expertise. Nurse managers are not typically trained in pharmacology and drug interactions. Consulting the hospital pharmacist is the best course of action to ensure safe administration of medications.
A nurse is caring for a patient who attacked a friend and is now admitted to the psychiatric unit. Which of the following actions should the nurse take first? Which action should the nurse take first for an aggressive patient?
- A. Establish a patient relationship.
- B. Explore the truth of the patient's statements.
- C. Set behavioral limits for the patient.
- D. Explain to the patient that the behavior was unacceptable.
Correct Answer: C
Rationale: The correct answer is C: Set behavioral limits for the patient. This is the first action the nurse should take to ensure the safety of the patient and others. By setting clear boundaries and limits, the nurse can help manage the patient's aggressive behavior and prevent any further harm. Establishing a patient relationship (A) is important but secondary to ensuring immediate safety. Exploring the truth of the patient's statements (B) can be addressed once the aggressive behavior is under control. Explaining to the patient that the behavior was unacceptable (D) may not be effective in the heat of the moment and should come after setting limits.
A patient with a history of migraines is at the clinic complaining of a throbbing headache. Which of the following questions should the nurse include in the assessment? Which question should the nurse ask for migraine assessment?
- A. Have you experienced any nausea or vomiting with your headache?
- B. Are the lights in this room bothering you?
- C. Have you noticed any confusion or clouded thinking?
- D. Did you feel weak before the headache started or do you feel weak now?
Correct Answer: A
Rationale: The correct answer is A: "Have you experienced any nausea or vomiting with your headache?" This question is crucial in assessing migraines as nausea and vomiting are common accompanying symptoms. Nausea and vomiting are associated with activation of the autonomic nervous system during migraines. The other options are not as directly related to migraines. B is more relevant to light sensitivity in migraines, C is more related to confusion or cognitive symptoms, and D is more focused on weakness, which are not typically primary symptoms of migraines.
A nurse is preparing to administer Ringer's lactate via continuous IV infusion at a rate of 120 mL/hr. The manual IV tubing's drop factor is 60 gtt/mL. How many gtt/min should the nurse set the manual IV infusion to deliver? How many gtt/min for Ringer's lactate infusion?
Correct Answer: 120
Rationale: The correct answer is 120 gtt/min. To calculate the infusion rate in gtt/min, you first convert the hourly rate to minutes by dividing 120 mL/hr by 60 min/hr, which equals 2 mL/min. Then, multiply the mL/min by the drop factor of 60 gtt/mL to get the answer of 120 gtt/min. This ensures the correct amount of Ringer's lactate is delivered per minute. Other choices are incorrect because they do not follow the correct calculation steps or involve incorrect conversions, leading to inaccurate infusion rates.