Nokea
A nurse is collecting data from a client who is taking dimenhydrinate to treat motion sickness. Which of the following findings is an adverse effect of this medication?
- A. Drowsiness
- B. Hypertension
- C. Polyuria
- D. Dependent edema
Correct Answer: A
Rationale: The correct answer is A: Drowsiness. Dimenhydrinate is an antihistamine commonly used for motion sickness, which can cause drowsiness as a common adverse effect due to its sedative properties. This is because it can cross the blood-brain barrier and affect the central nervous system, leading to drowsiness. The other options are incorrect because hypertension (B) is not a known adverse effect of dimenhydrinate, polyuria (C) is excessive urination, which is not typically associated with this medication, and dependent edema (D) is swelling due to fluid buildup, which is also not commonly caused by dimenhydrinate. Therefore, the correct adverse effect to expect with dimenhydrinate use is drowsiness.
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A nurse is caring for a client who has prescriptions for spironolactone and lisinopril. The nurse should monitor for which of the following adverse effects?
- A. Hypoglycemia
- B. Hyperkalemia
- C. Hyperglycemia
- D. Hypokalemia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic and can lead to an increase in potassium levels (hyperkalemia). Lisinopril, an ACE inhibitor, can also contribute to this effect. Monitoring for hyperkalemia is crucial as it can lead to serious cardiac complications.
A: Hypoglycemia is not typically associated with spironolactone or lisinopril.
C: Hyperglycemia is not a common adverse effect of spironolactone or lisinopril.
D: Hypokalemia is unlikely with spironolactone, as it tends to increase potassium levels.
In summary, monitoring for hyperkalemia is essential when a client is taking spironolactone and lisinopril due to the potential for adverse cardiac events.
A nurse is reinforcing teaching with a client who has a new prescription for alendronate for the treatment of osteoporosis. The nurse should instruct the client to monitor for which of the following adverse effects?
- A. Anorexia
- B. Jaw pain
- C. Insomnia
- D. Bruising
Correct Answer: B
Rationale: The correct answer is B: Jaw pain. Alendronate, a bisphosphonate medication used to treat osteoporosis, can cause a rare but serious side effect called osteonecrosis of the jaw (ONJ), characterized by jaw pain, swelling, and possible infection. It is essential for the nurse to instruct the client to monitor for any signs of jaw pain to promptly report to their healthcare provider. Anorexia (A), insomnia (C), and bruising (D) are not typically associated with alendronate use for osteoporosis and would not be common adverse effects that the client needs to monitor for.
A nurse is preparing to administer enoxaparin 5,000 units subcutaneous to a client. Which of the following actions should the nurse take?
- A. Insert the needle at a 45° or 90° angle.
- B. Hold the skin taut during administration
- C. Massage the injection site after administrating the enoxaparin.
- D. Use a 4 cm (1.6in) needle
Correct Answer: A
Rationale: The correct answer is A: Insert the needle at a 45° or 90° angle. When administering enoxaparin subcutaneously, the nurse should insert the needle at a 45° or 90° angle to ensure proper delivery into the subcutaneous tissue. Angling the needle helps prevent injecting the medication too deeply or too superficially, ensuring optimal absorption and effectiveness. Holding the skin taut (choice B) is not required for subcutaneous injections. Massaging the injection site (choice C) after administering enoxaparin is not recommended as it can cause irritation or bruising. Using a 4 cm needle (choice D) is not specified for enoxaparin administration and may not be appropriate for all clients.
A nurse is caring for a client who has ulcerative colitis and is receiving sulfasalazine. Which of the following findings requires immediate intervention?
- A. Anorexia
- B. Arthralgia
- C. Nausea
- D. Wheezing
Correct Answer: D
Rationale: The correct answer is D: Wheezing. Wheezing is a sign of a severe allergic reaction to sulfasalazine, known as Stevens-Johnson syndrome, which is a medical emergency requiring immediate intervention to prevent respiratory distress and potential anaphylaxis. Anorexia, arthralgia, and nausea are common side effects of sulfasalazine but do not indicate an immediate threat to the client's well-being. Wheezing is the most critical finding that needs urgent attention.
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.