Nokea
A nurse is collecting data from a client following the administration of a new medication. Which of the following findings should the nurse identify as a manifestation of an allergic reaction?
- A. Jaundice
- B. Urticaria
- C. Bradycardia
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Urticaria. Urticaria, also known as hives, is a common manifestation of allergic reactions. It presents as raised, red, itchy welts on the skin. Jaundice (A) is associated with liver dysfunction, not typically an allergic reaction. Bradycardia (C) is a slow heart rate and not a common allergic reaction symptom. Hypertension (D) is high blood pressure and is not typically associated with allergic reactions. Therefore, based on the symptoms of an allergic reaction, urticaria is the most appropriate choice.
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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 checking the forearm of a client who received a tuberculin skin test 48 hr ago. Which of the following findings at the injection site should indicate to the nurse a positive result?
- A. Excoriation
- B. Firmness
- C. Ulceration
- D. Bleeding
Correct Answer: B
Rationale: The correct answer is B: Firmness. A positive tuberculin skin test is indicated by induration (firmness) at the injection site, not redness, swelling, or pain. Induration of 10mm or more is considered positive for most individuals. Excoriation (choice A) refers to scratching or scraping of the skin, not a typical sign of a positive tuberculin skin test. Ulceration (choice C) involves open sores, not related to a tuberculin skin test. Bleeding (choice D) at the injection site is not a sign of a positive result.
A nurse is reviewing the medication administration record of a client who has a wound infection. The client has prescriptions for cefotetan and an NSAID. The nurse should monitor for which of the following medication interactions?
- A. Bleeding
- B. Dysrhythmias
- C. Dizziness
- D. Jaundice
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Cefotetan is a cephalosporin antibiotic that can increase the risk of bleeding when taken with NSAIDs due to their additive effects on platelet function. The combination can lead to gastrointestinal bleeding or bruising. Dysrhythmias (choice B) are not typically associated with this drug combination. Dizziness (choice C) and jaundice (choice D) are not common interactions with cefotetan and NSAIDs.
A nurse is reinforcing teaching with a client who has angina and a new prescription of nitroglycerin sublingual. Which of the following statements by the client indicates an understanding of the teaching?
- A. If my pain is not relieved in 20 minutes, I will take a second tablet.'
- B. I will keep my tablets on a shelf in the bathroom.'
- C. I should be sure to swallow the tablet whole.'
- D. If my mouth is dry, I will take a sip of water before I take the tablet.'
Correct Answer: D
Rationale: The correct answer is D: "If my mouth is dry, I will take a sip of water before I take the tablet." This statement indicates an understanding of how to properly administer nitroglycerin sublingual. Taking the medication under the tongue allows for faster absorption. Taking a sip of water before taking the tablet helps moisten the mouth and aids in the absorption of the medication. This step is crucial for the effectiveness of nitroglycerin in relieving angina symptoms.
Other choices are incorrect:
A: Taking a second tablet before the 20-minute mark is not recommended as it can lead to an overdose.
B: Keeping tablets in the bathroom exposes them to moisture, affecting their potency.
C: Nitroglycerin sublingual should not be swallowed but dissolved under the tongue for rapid absorption.
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.