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A nurse is reinforcing teaching with the parents of a 1-year-old client following the administration of the measles, mumps, and rubella virus vaccine (MMR). Which of the following adverse effects should the nurse instruct the parents to report to the provider?
- A. Glandular swelling around the jaw
- B. Redness around the injection site
- C. Temperature 37.3° C (99.2° F)
- D. Shortness of breath
Correct Answer: D
Rationale: The correct answer is D: Shortness of breath. Shortness of breath can indicate a severe allergic reaction or anaphylaxis, which is a rare but serious adverse effect of the MMR vaccine. It is crucial to report this immediately to the healthcare provider for prompt evaluation and management to prevent any complications.
A: Glandular swelling around the jaw is a common and mild side effect of the MMR vaccine, typically resolving on its own and not requiring immediate medical attention.
B: Redness around the injection site is a common and expected reaction to the vaccine, usually resolving without intervention.
C: A temperature of 37.3° C (99.2° F) is a low-grade fever, which can be a normal response to vaccination and typically does not require urgent medical attention.
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Provider Prescriptions: Tetracycline 500 mg PO twice daily; Vital Signs Initial visit: Temperature 37.1° C (98.8° F), Heart rate 82/min, Blood pressure 118/76 mm Hg, Respiratory rate 16/min, SpO2 99% on room air; Current visit: Temperature 37.5° C (99.5° F), Heart rate 84/min, Blood pressure 122/72 mm Hg, Respiratory rate 18/min, SpO2 99% on room air; History and Physical Initial visit: Client is a 20-year-old female who presents with report of worsening acne over the past few months. Severe inflammatory acne noted over face, neck, and upper back. Client has no significant medical or surgical history. Discussed skin hygiene and use of over-the-counter acne treatments. Current visit: Client reports no improvement in acne since prior visit 2 months ago. Client states they have been gently washing their skin twice daily and using acne treatments as recommended. Client states they are self-conscious and avoids certain social activities. No change in acne noted on assessment. Tetracycline prescribed. Will have the client return to the clinic in 4 weeks.
The nurse should identify that the client is at risk for developing ________and _________
- A. Increased cholesterol level
- B. Gastridium difficite-associated diarrhea
- C. Elevated blood glucose level
- D. Gallstones
- E. Vaginal yeast infection
Correct Answer: B, E
Rationale: Correct Answer: B, E
Rationale:
1. Choice B: Gastridium difficile-associated diarrhea is a risk for clients on antibiotics, disrupting gut flora balance.
2. Choice E: Vaginal yeast infection risk increases with antibiotic use, disrupting vaginal flora.
Summary:
- A, C, D: These choices are not directly related to antibiotic use or disruption of flora balance.
- B, E: Antibiotics can lead to imbalances in gut and vaginal flora, increasing the risk for these conditions.
A nurse is collecting data from a client who was taking oxycodone four times a day for chronic pain and reports discontinuing the medication 10 days ago. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Constricted pupils
- C. Insomnia
- D. Constipation
Correct Answer: C
Rationale: The correct answer is C: Insomnia. When a client discontinues oxycodone, a narcotic analgesic, they may experience withdrawal symptoms such as insomnia due to the abrupt cessation of the medication affecting the central nervous system. Hypotension (A) is not typically a withdrawal symptom of oxycodone. Constricted pupils (B) are a sign of opioid intoxication, not withdrawal. Constipation (D) is a common side effect of opioid use but is not a typical withdrawal symptom in this scenario.
A nurse is preparing to administer regular insulin 4 units and NPH insulin 10 units subcutaneously to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?
- A. Inject 10 units of air into the NPH insulin vial.
- B. Draw up 10 units from the NPH insulin vial.
- C. Inject 4 units of air into the regular insulin vial.
- D. Draw up 4 units from the regular insulin vial.
Correct Answer: C
Rationale: The correct answer is C: Inject 4 units of air into the regular insulin vial. This action is done to prevent negative pressure in the vial, making it easier to withdraw the correct dose of insulin. By injecting air first, the nurse ensures that the exact amount of insulin can be withdrawn accurately without causing any damage to the vial or affecting the dose.
Choice A is incorrect as injecting air into the NPH insulin vial is not necessary before drawing up the insulin. Choice B is incorrect as drawing up the NPH insulin before preparing the regular insulin would be out of sequence. Choice D is incorrect as drawing up the regular insulin before injecting air into the vial could lead to difficulty in withdrawing the correct dose.
A nurse is reinforcing teaching with a client who has a new prescription for naproxen. Which of the following is a potential adverse effect that the nurse should instruct the client to report to the provider?
- A. Increased energy levels
- B. Black, tarry stools
- C. Improved appetite
- D. Mild headache
Correct Answer: B
Rationale: The correct answer is B: Black, tarry stools. This is a potential adverse effect of naproxen, indicating gastrointestinal bleeding. It is crucial to report this to the provider immediately to prevent serious complications. Increased energy levels (A), improved appetite (C), and mild headache (D) are common side effects of naproxen and do not require immediate medical attention. The priority is to address potential serious adverse effects like gastrointestinal bleeding.
A nurse is reinforcing teaching with a client who has a prescription for alendronate. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will drink orange juice when I take this medication.
- B. I will remain seated for 30 minutes after I take my medication.
- C. I will take this medication right before I go to bed.
- D. I can take this medication just once a month.
Correct Answer: C
Rationale: The correct answer is C: "I will take this medication right before I go to bed." Alendronate should be taken on an empty stomach, in the morning, at least 30 minutes before the first food, drink, or medication of the day. Taking it before bed ensures the client has an empty stomach. Choice A is incorrect because orange juice can interfere with alendronate absorption. Choice B is incorrect as sitting upright for 30 minutes after taking the medication is the recommended action. Choice D is incorrect as alendronate is typically taken weekly, not monthly.