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A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following findings should the nurse expect?
- A. Tachypnea
- B. Sedation
- C. Dilated pupils
- D. Tachycardia
Correct Answer: B
Rationale: The correct answer is B: Sedation. Oxycodone is an opioid that depresses the central nervous system, leading to sedation as a common manifestation of toxicity. Tachypnea (A) is more commonly associated with opioid withdrawal rather than toxicity. Dilated pupils (C) are more indicative of stimulant toxicity, not opioids. Tachycardia (D) is unlikely with oxycodone toxicity due to its depressant effects on the cardiovascular system. Other choices are not relevant to oxycodone toxicity.
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A nurse is caring for an adult client who is receiving albuterol inhalation treatments. For which of the following adverse effects should the nurse monitor the client? (Select all that apply.)
- A. Shakiness
- B. Fatigue
- C. Tinnitus
- D. Tachycardia
- E. Palpitations
Correct Answer: A, D, E
Rationale: The correct adverse effects to monitor for with albuterol inhalation treatments are shakiness, tachycardia, and palpitations. Albuterol is a beta-2 adrenergic agonist that can cause sympathetic stimulation, leading to these specific side effects. Shakiness is due to the stimulation of beta-2 receptors in muscles, tachycardia results from the activation of beta-1 receptors in the heart, and palpitations can occur due to increased heart rate. Fatigue and tinnitus are not commonly associated with albuterol use, making choices B and C incorrect. In summary, the correct answers are related to the sympathetic effects of albuterol, while the incorrect choices are not typically seen with this medication.
A nurse working in an urgent care clinic is collecting data from a client who takes montelukast. Which of the following is an expected therapeutic effect of this medication?
- A. Improved peripheral vasodilation
- B. Neutralized gastric acid
- C. Increased WBC count
- D. Reduced bronchial inflammation
Correct Answer: D
Rationale: The correct answer is D: Reduced bronchial inflammation. Montelukast is a leukotriene receptor antagonist used to manage asthma and allergic rhinitis by reducing inflammation and bronchoconstriction in the airways. This improves breathing and reduces symptoms. Option A is incorrect as montelukast does not affect peripheral vasodilation. Option B is incorrect as it does not neutralize gastric acid. Option C is incorrect as montelukast does not affect white blood cell count. In summary, montelukast's main therapeutic effect is reducing bronchial inflammation, making option D the correct choice.
A nurse is caring for a client who is postoperative. For which of the following findings should the nurse administer ondansetron?
- A. Client reports nausea.
- B. Client reports incisional pain.
- C. Client's respiratory rate is 14/min.
- D. Client's blood pressure is 110/72 mm Hg.
Correct Answer: A
Rationale: The correct answer is A. Ondansetron is commonly used to treat nausea and vomiting, especially in postoperative clients. Administering ondansetron for nausea can help alleviate the client's discomfort and prevent further complications. Choices B, C, and D do not indicate a need for ondansetron as they are not directly related to nausea. Choice B suggests a need for pain management, choice C indicates normal respiratory rate, and choice D shows a stable blood pressure. Therefore, administering ondansetron would not be appropriate for these findings.
Vital Signs Day 1: Temperature 37.5° C (99.5° F), Heart rate 98/min, Respiratory rate 20/min, Blood pressure 180/86 mm Hg, Oxygen saturation 95% on room air, Weight 90 kg (198 lb); 2 months later: Temperature 37.5° C (99.5° F), Heart rate 48/min, Respiratory rate 20/min, Blood pressure 140/76 mm Hg, Oxygen saturation 97% on room air, Weight 91 kg (200 lb)
The nurse is evaluating the client's response to the medication. The client's ___________ and ____________ indicate the client's condition is improving.
- A. HDL Level
- B. Heart rate
- C. Potassium level
- D. Weight
- E. blood Pressure
Correct Answer: B, E
Rationale: The correct answer is B, Heart rate and E, Blood Pressure. Monitoring heart rate and blood pressure are vital signs that reflect the overall cardiovascular function and response to medication. An improvement in heart rate and blood pressure indicates better circulation and cardiac output, suggesting the client's condition is improving. The other choices (A, C, D) do not directly reflect the client's cardiovascular status and are not appropriate indicators of medication response. Weight (D) can fluctuate for various reasons, and HDL level (A) and Potassium level (C) are important but specific to different aspects of health. Thus, heart rate and blood pressure are the most relevant indicators in this context.
A nurse is assisting in the development of an in-service about the varicella vaccine. The nurse should include which of the following examples as a contraindication for receiving the vaccine?
- A. A client who is breastfeeding
- B. A client who has an allergy to latex
- C. A client who has a sinus infection
- D. A client who is pregnant
Correct Answer: D
Rationale: The correct answer is D: A client who is pregnant. Varicella vaccine is contraindicated during pregnancy due to potential risks to the fetus. Varicella vaccine is a live vaccine and can pose a risk of transmission to the fetus, potentially causing harm. Other choices are incorrect because: A: Breastfeeding is not a contraindication for varicella vaccine. B: Latex allergy is not a contraindication for varicella vaccine. C: Sinus infection is not a contraindication for varicella vaccine.