Nokea
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.
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A nurse is reinforcing discharge teaching with a client who has tuberculosis and a prescription for rifampin. Which of the following client statements indicates an understanding of the teaching?
- A. I can discontinue this medication after one negative sputum culture.'
- B. I should take this medication on an empty stomach.'
- C. I should expect to have ringing in my ears.'
- D. I can expect to have joint pain.'
Correct Answer: B
Rationale: The correct answer is B: "I should take this medication on an empty stomach." Rifampin should be taken on an empty stomach to maximize absorption. Taking it with food can decrease its effectiveness. Choice A is incorrect because rifampin treatment typically lasts several months, not just until one negative sputum culture. Choices C and D are incorrect as they are not common side effects of rifampin. The client should be informed about potential side effects, such as gastrointestinal upset or discoloration of bodily fluids, but not ringing in the ears or joint pain.
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.
Vital Signs
Nurses Notes
History and Physical
Initial visit:
Temperature 36.5° C (97.7° F)
Heart rate 68/min
Blood pressure 116/70 mm Hg
Respiratory rate 16/min
SpO2 98% on room air
Follow-up visit 2 weeks later:
Temperature 36.7° C (98.1°F)
Heart rate 86/min
Blood pressure 130/80 mm Hg
Respiratory rate 18/min
SpO2 99% on room air
Select the 6 statements the nurse should include when reinforcing teaching to the client about the newly prescribed medication (sumatriptan).
- A. Do not take more than 200 milligrams of this medication within 24 hours.'
- B. You can take a second dose of this medication at least 2 hours after the initial dose if the headache persists.'
- C. You should discontinue this medication if pregnancy is planned or suspected.'
- D. You might experience a rash on your skin while taking this medication.'
- E. You might experience a feeling of pressure in your chest after taking this medication.'
- F. This medication can cause you to feel tired.'
- G. This medication should start to alleviate the headache within 1 hour.'
Correct Answer: A,B,C,E,F,G
Rationale: The correct statements are A, B, C, E, F, and G. A: Correct dose limit to prevent overdose. B: Advises on timing for second dose if needed. C: Important to stop if pregnancy is planned. E: Chest pressure is a potential side effect. F: Fatigue is a possible side effect. G: Expected time frame for headache relief. These statements cover dosage, timing, potential side effects, pregnancy precautions, and expected outcomes. Other options lack crucial information or provide incorrect guidance, such as D, which mentions a rash that is not a common side effect of sumatriptan.
A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim-sulfamethoxazole. Which of the following statements by the client should indicate to the nurse that the medication is effective?
- A. My appetite is increased.'
- B. I don't have a headache anymore.'
- C. My voice is no longer hoarse.'
- D. I am feeling more alert.'
Correct Answer: C
Rationale: The correct answer is C: "My voice is no longer hoarse." This statement indicates the effectiveness of diphenhydramine, an antihistamine used to treat allergic reactions. Hoarseness is a common symptom of allergic reactions, so if the client's voice is no longer hoarse, it suggests that the medication has alleviated the allergic response.
A: Increased appetite is not a direct indicator of the effectiveness of diphenhydramine in treating an allergic reaction.
B: Relief from headaches is not a specific symptom related to allergic reactions or a typical indicator of diphenhydramine effectiveness.
D: Feeling more alert is not a direct indicator of the effectiveness of diphenhydramine in treating allergic reactions.
Therefore, option C is the most appropriate choice as it directly relates to the specific symptom of the allergic reaction that diphenhydramine is intended to treat.
A nurse is caring for a client who has Graves' disease and is to start therapy with propylthiouracil. The nurse should expect which of the following outcomes?
- A. Increased Hct
- B. Decreased WBC count
- C. Decreased heart rate
- D. Increased blood pressure
Correct Answer: C
Rationale: The correct answer is C: Decreased heart rate. Propylthiouracil is an antithyroid medication used to treat hyperthyroidism, such as Graves' disease. It works by inhibiting the production of thyroid hormones. A decreased heart rate is an expected outcome as hyperthyroidism can cause tachycardia (increased heart rate), and treatment with propylthiouracil helps normalize heart rate.
Incorrect options:
A: Increased Hct - Propylthiouracil does not affect hematocrit levels.
B: Decreased WBC count - Propylthiouracil does not typically affect white blood cell count.
D: Increased blood pressure - Propylthiouracil does not lead to an increase in blood pressure.