Nokea
In teaching bleeding precautions to a client with leukemia, the PN should include which of the following instructions?
- A. Use a soft toothbrush
- B. Use dental floss daily
- C. Hold pressure on any scrapes for 1-2 minutes
- D. Use a triple-edged razor
Correct Answer: A
Rationale: A soft toothbrush minimizes gum bleeding in leukemia clients with low platelets. Dental floss and razors increase bleeding risk, and pressure should be held for 5-10 minutes.
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The nurse is caring for the client taking atorvastatin. The nurse should assess for which adverse effects?
- A. Constipation and hemorrhoids
- B. Muscle pain and weakness
- C. Fatigue and dysrhythmias
- D. Flushing and postural hypotension
Correct Answer: B
Rationale: A: Bile acid sequestrants act by inhibiting bile acids from absorption by the small intestine. This results in fewer bile acids in the small intestine, which may lead to constipation and hemorrhoids. B: Atorvastatin (Lipitor) is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor (statin) used to lower lipid levels. Statins can cause muscle tissue injury manifested by muscle ache or weakness. Muscle injury can progress to myositis (muscle inflammation) or rhabdomyolysis (muscle disintegration). C: Diarrhea, not constipation, has been found to be a side effect of statin medications. D: Side effects of niacin, a lipid-lowering agent, include flushing, dysrhythmias, and postural hypotension.
Which of these medications has the least risk of causing tinnitus?
- A. Aspirin
- B. Lasix
- C. Gentamicin
- D. Fluoxetine
Correct Answer: D
Rationale: Gentamicin, Lasix, and Aspirin are all ototoxic drugs that have a potential side effect of causing tinnitus, a ringing in the ear. Fluoxetine, an SSRI, is not typically associated with tinnitus.
The nurse working on the pediatric unit has scheduled medications to administer at this time. Which assessments should prompt the nurse to conclude that the prescribed medication should be withheld and the HCP immediately notified?
- A. Oral hydrocodone with acetaminophen to the 10-year-old with burn injuries who is feeling dizzy and light-headed
- B. Oral acetaminophen to the 6-month-old with a fever of 102°F (38.9°C) from an infection who has developed a rash
- C. Clindamycin IV to the 16-year-old male with aspiration pneumonia from near-drowning who has a BP of 92/56 mm Hg
- D. Phenobarbital IV to the 5-year-old with intermittent seizures who states feeling tired and appears to be drowsy
Correct Answer: C
Rationale: A: Dizziness and light-headedness are side effects of hydrocodone with acetaminophen (Vicodin), and the nurse may choose to withhold a scheduled dose. These are not potentially life-threatening or warranting an immediate call to the HCP. B: A rash is a side effect of acetaminophen (Tylenol). However, the rash is not potentially life-threatening or warranting an immediate call to the HCP. C: An adverse effect of clindamycin (Cleocin) is hypotension. A BP of 92/56 mm Hg is low for a 16-year-old. Normal BP for a 16-year-old male is 111/63 mm Hg to 136/90 mm Hg, depending on height percentile. The nurse should compare the previous BP readings with the current one to determine the degree of BP variation and then immediately notify the HCP because the BP can decrease further. D: Tiredness and drowsiness are side effects of phenobarbital (Luminal). However, these are expected. The nurse would not withhold phenobarbital unless there were additional neurological alterations that would warrant contacting the HCP.
The HCP prescribes risperidone to manage the hallucinations of the client diagnosed with paranoid schizophrenia. Which client statements reflect a need for further education regarding the medication's side effects? Select all that apply.
- A. Diarrhea may be a problem for me.
- B. I'll most likely develop high blood pressure.
- C. Being too nervous is a side effect of my medicine.
- D. I will need to watch what I eat so I won't gain weight.
- E. Getting up too quickly when I'm sitting can make me dizzy.
- F. I will need to be careful driving because this can make me drowsy.
Correct Answer: A,B
Rationale: Constipation, not diarrhea, and hypotension, not hypertension, are side effects of risperidone, indicating a need for further education.
The client undergoing detoxification from chronic alcohol abuse is to receive Phenobarbital 120 mg IM and promethazine 50 mg IM. Which explanation by the nurse about using this medication combination is correct?
- A. Promethazine will prevent a potential allergic reaction to the phenobarbital.
- B. Combining promethazine and phenobarbital will have a greater sedative effect.
- C. Promethazine will decrease the nausea from phenobarbital when it is given IM.
- D. Combining these reduces the sedative effects and prevents a ‘hangover' feeling.
Correct Answer: B
Rationale: Promethazine (Phenergan) potentiates the CNS depression of phenobarbital, producing a greater sedative effect.