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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. Tachycardia
- B. Sedation
- C. Dilated pupils
- D. Tachypnea
Correct Answer: B
Rationale: The correct answer is B: Sedation. Oxycodone is an opioid that depresses the central nervous system, leading to symptoms such as sedation or drowsiness. This is because opioids like oxycodone bind to opioid receptors in the brain, causing a calming effect. Tachycardia (A) and dilated pupils (C) are more commonly associated with stimulant toxicity rather than opioid toxicity. Tachypnea (D) is not a typical finding in opioid toxicity as opioids tend to depress the respiratory system, causing respiratory depression instead.
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A nurse is reinforcing teaching about phenytoin with a client who had a tonic-clonic seizure. Which of the following information should the nurse include in the teaching?
- A. Taking ginkgo biloba increases phenytoin levels.
- B. Taking phenytoin diminishes potassium levels.
- C. Monitor for gingival hyperplasia.
- D. Minimize exposure to sunlight.
Correct Answer: C
Rationale: The correct answer is C: Monitor for gingival hyperplasia. This is important because phenytoin can cause gingival overgrowth, leading to oral health issues. The nurse should educate the client to maintain good oral hygiene and visit the dentist regularly for check-ups.
A: Taking ginkgo biloba increases phenytoin levels - This statement is incorrect. Ginkgo biloba is known to interact with certain medications, but it does not specifically increase phenytoin levels.
B: Taking phenytoin diminishes potassium levels - This statement is incorrect. Phenytoin does not directly affect potassium levels. It is more likely to cause issues with calcium and vitamin D metabolism.
D: Minimize exposure to sunlight - This statement is incorrect. While some antiepileptic medications can increase sensitivity to sunlight, phenytoin is not typically associated with this side effect.
Overall, monitoring for gingival hyperplasia is the most relevant information for the client
Nurses' Notes
Plan of Care
Provider Prescriptions
Vital Signs
6 months ago:
The client was diagnosed with epilepsy during childhood. The client reports not having seizures for 2 years. The client has weaned off all seizure medications. The client was informed to return to the office for a follow-up in 6 months and to call the office if seizure activity resumes.
Today:
The client reports having a seizure this morning. Provider aware and new prescription obtained.
Click to highlight the findings that require immediate follow-up as contraindications to the prescribed prescription (phenytoin).
- A. Client reports having three to four alcoholic beverages a couple times per week.
- B. Last bowel movement was 3 days ago
- C. Last menstrual period was 3 months ago
- D. Client takes diazepam as needed for anxiety.
Correct Answer: A,C
Rationale: First, Step 1: The prescribed medication is phenytoin, an antiepileptic drug. Step 2: Alcohol consumption can interact with phenytoin, causing increased sedation and affecting liver function. Therefore, client reporting alcohol intake requires immediate follow-up. Step 3: (0,0,1,0) Phenytoin can also affect menstrual cycles, so the client's last menstrual period being 3 months ago is a potential contraindication that needs follow-up. Step 4: (0,1,0,0) Last bowel movement being 3 days ago is not directly related to phenytoin use. Step 5: (0,0,0,1) Diazepam for anxiety is not a direct contraindication to phenytoin use. Therefore, choices A and C are correct as they indicate potential issues requiring immediate attention, while choices B and D do not
A nurse is reinforcing discharge teaching with a client who has a new diagnosis of type 2 diabetes mellitus and a prescription for exenatide. Which of the following instructions should the nurse include in the teaching?
- A. Contact the provider if you experience unexplained muscle pain.
- B. Take the medication at bedtime.
- C. Discard excess medication after 60 days.
- D. Inject the medication into the subcutaneous tissue of your abdomen.
Correct Answer: D
Rationale: The correct answer is D: Inject the medication into the subcutaneous tissue of your abdomen. Exenatide is a medication that is administered through subcutaneous injection, typically into the abdomen. This is the correct route of administration to ensure proper absorption and effectiveness of the medication. Option A is incorrect as it is not directly related to the administration of exenatide. Option B is incorrect because exenatide is usually taken before meals, not at bedtime. Option C is incorrect as the disposal timeline for exenatide is typically shorter than 60 days.
A nurse is reinforcing teaching about the IPLEDGE program with a female client who has a new prescription for isotretinoin. The nurse should tell the client that which of the following is a requirement of the program?
- A. Clients must have a Papanicolaou test every 6 months during treatment.
- B. Sexually active female clients must use two forms of birth control during treatment.
- C. Clients must begin a daily supplement of vitamin A for 1 month prior to initiating therapy.
- D. Female clients must have a negative mammogram prior to beginning therapy.
Correct Answer: B
Rationale: The correct answer is B: Sexually active female clients must use two forms of birth control during treatment. This is a requirement of the IPLEDGE program for isotretinoin due to the teratogenic effects of the medication. Isotretinoin can cause severe birth defects if taken during pregnancy, so using two forms of birth control is crucial to prevent pregnancy while on the medication. This requirement aims to ensure the safety of the fetus.
Choices A, C, and D are incorrect because they are not specific requirements of the IPLEDGE program for isotretinoin. A Papanicolaou test every 6 months, a daily supplement of vitamin A, and a negative mammogram are not mandatory components of the program. It is essential to focus on the specific requirements outlined by the IPLEDGE program to ensure the safe use of isotretinoin.
A nurse is preparing to administer a daily dose of warfarin to a client. Which of the following laboratory values should the nurse check prior to administration?
- A. WBC
- B. INR
- C. Platelets
- D. APTT
Correct Answer: B
Rationale: The correct answer is B: INR. The International Normalized Ratio (INR) is a crucial laboratory value to monitor before administering warfarin, an anticoagulant. INR helps assess the effectiveness and safety of warfarin therapy by measuring the clotting time of blood. This ensures that the dose is within the therapeutic range to prevent clotting or bleeding complications. Checking white blood cells (WBC), platelets, or activated partial thromboplastin time (APTT) is not directly related to warfarin administration. WBC count indicates infection or inflammation, platelets assess clotting ability, and APTT evaluates the intrinsic pathway of coagulation. However, these values do not specifically guide warfarin dosing like the INR does.