Nokea
For which of the following adverse effects should the nurse instruct the client taking acetazolamide for chronic open-angle glaucoma to monitor and report?
- A. Tingling of fingers
- B. Constipation
- C. Weight gain
- D. Oliguria
Correct Answer: A
Rationale: The correct answer is A: Tingling of fingers. Acetazolamide is a diuretic commonly used to treat glaucoma. Tingling of fingers is associated with electrolyte imbalances caused by the drug's diuretic effect. This symptom may indicate hypokalemia, a potential side effect of acetazolamide. Monitoring and reporting this symptom promptly can prevent serious complications.
Other choices are incorrect because:
B: Constipation is not a common side effect of acetazolamide.
C: Weight gain is unlikely as acetazolamide is a diuretic causing fluid loss.
D: Oliguria, decreased urine output, is not a usual side effect of acetazolamide.
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Which of the following laboratory results should the nurse report to the provider?
- A. A client who has a prescription for heparin and an aPTT of 90 seconds (normal range 30-40 sec)
- B. A client who has a prescription for heparin and an aPTT of 65 seconds (normal range 30-40 sec)
- C. A client who has a prescription for warfarin and an INR of 3.0 (normal range 0.8-1.1)
- D. A client who has a prescription for warfarin and an INR of 2.0 (normal range 0.8-1.1)
Correct Answer: A
Rationale: The correct answer is A. An aPTT of 90 seconds is above the normal range of 30-40 sec, indicating the client is at risk for bleeding due to excessive anticoagulation with heparin. This result should be reported to the provider immediately for further evaluation and possible adjustment of the heparin dose to prevent bleeding complications. Choices B, C, and D all fall within the normal range for their respective medications, so they do not require immediate reporting.
A nurse is teaching a client about cyclobenzaprinWhich of the following client statements should indicate to the nurse that the teaching about cyclobenzaprine was effective?
- A. I will have increased saliva production
- B. I will continue taking the medication until the rash disappears
- C. I will taper off the medication before discontinuing it
- D. I will report any urinary incontinence
Correct Answer: C
Rationale: Correct Answer: C. "I will taper off the medication before discontinuing it."
Rationale: Tapering off cyclobenzaprine is important to prevent withdrawal symptoms due to its muscle relaxant properties. Abruptly stopping the medication can lead to adverse effects. This statement indicates understanding of proper medication management.
Incorrect Choices:
A: Increased saliva production is not a common side effect of cyclobenzaprine.
B: Continuing the medication until the rash disappears is not relevant to cyclobenzaprine.
D: Reporting urinary incontinence is important but not specifically related to cyclobenzaprine teaching.
Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism in a client taking haloperidol?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol, characterized by symptoms resembling Parkinson's disease. A shuffling gait, where the client takes small steps with feet barely leaving the floor, is a classic manifestation. Serpentine limb movement (A) is not typically associated with pseudoparkinsonism. Nonreactive pupils (C) can be a sign of anticholinergic toxicity, not pseudoparkinsonism. Smacking lips (D) is more indicative of tardive dyskinesia, another side effect of antipsychotics.
A nurse is assessing a client after administering a second dose of cefazolin IV. The nurse notes the client has anxiety, hypotension, and dyspneWhich of the following medications should the nurse administer first?
- A. Diphenhydramine
- B. Albuterol inhaler
- C. Epinephrine
- D. Prednisone
Correct Answer: C
Rationale: The correct answer is C: Epinephrine. When a client exhibits symptoms of anxiety, hypotension, and dyspnea after receiving cefazolin IV, it indicates a severe allergic reaction/anaphylaxis. Epinephrine is the first-line medication for anaphylaxis as it acts quickly to reverse the symptoms by constricting blood vessels, increasing blood pressure, and opening airways. Diphenhydramine (A) is an antihistamine that can be given as a second-line treatment. Albuterol inhaler (B) is used for bronchospasm but is not the first choice in anaphylaxis. Prednisone (D) is a corticosteroid that may be used later for inflammation but is not the initial treatment for anaphylaxis.
Complete the following sentence by using the lists of options. Upon analyzing the assessment findings, the nurse identifies that the client is at risk for _______ due to _______.
- A. concurrent medication use
- B. recent illness
- C. activity level
Correct Answer: A
Rationale: The correct answer is A: concurrent medication use. This is because identifying a client at risk for a condition due to concurrent medication use is crucial in nursing assessment. Medications can interact with each other, leading to adverse effects or reduced efficacy. Recent illness (B) and activity level (C) are important factors but do not directly relate to the risk due to medication use. The other choices (D, E, F, G) are irrelevant and do not address the potential risks associated with medication interactions. Thus, A is the most appropriate choice for identifying a client's risk based on assessment findings related to medication use.