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Keflex 250 mg PO q6h is ordered for an adult. The nurse notes that the client's history indicates that she has an allergy to penicillin. What is the most appropriate initial action for the nurse?
- A. Notify the physician
- B. Observe the client carefully after giving the medication
- C. Administer the Keflex IV instead of PO
- D. Ask the client to describe the reaction that she had to penicillin
Correct Answer: D
Rationale: There is often a cross-allergy between penicillin and cephalosporins like Keflex. The nurse should first determine the type of reaction to assess if Keflex is safe.
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A young woman delivered a 7-lb, 8-oz baby boy spontaneously. Ergotrate 0.4 mg q6h for five days is ordered. A half-hour after the nurse administers the first dose, she complains of abdominal cramping. The nurse's best response is based on which understanding?
- A. Cramping indicates a serious adverse reaction.
- B. Cramping can be reduced by abdominal breathing.
- C. The medication is having the desired effect.
- D. The dosage needs to be reduced.
Correct Answer: C
Rationale: Ergotrate causes uterine contractions, leading to cramping, which is the intended effect to prevent postpartum hemorrhage.
The nurse is caring for a client with schizophrenia who has been treated with quetiapine (Seroquel) for 1 month. Today the client is increasingly agitated and complains of muscle stiffness. Which of these findings should be reported to the health care provider?
- A. Elevated temperature and sweating
- B. Decreased pulse and blood pressure
- C. Mental confusion and general weakness
- D. Muscle spasms and seizures
Correct Answer: A
Rationale: Elevated temperature and sweating. Neuroleptic malignant syndrome (NMS) is a rare disorder that can occur as a side effect of antipsychotic medications. It is characterized by muscular rigidity, tachycardia, hyperthermia, sweating, altered consciousness, autonomic dysfunction, and increase in CPK. This is a life-threatening complication.
The charge nurse is observing the new graduate administering a fentanyl (Duragesic) patch to a client diagnosed with cancer. Which action by the new graduate requires intervention by the charge nurse?
- A. The new graduate documents the date and time on the patch.
- B. The new graduate removes the patch 24 hours after it is placed on the client.
- C. The new graduate rotates the application site on the client's body.
- D. The new graduate checks the client's name band and date of birth.
Correct Answer: B
Rationale: Fentanyl patches last 72 hours; removing at 24 hours is incorrect and requires intervention. Dating, rotating sites, and ID checks are correct.
An adult client is being treated for genital herpes with acyclovir (Zovirax) tablets. Which statement she makes indicates that she understands her therapy?
- A. It is safe now to have sexual relations.
- B. I will stay home from work until the blisters are gone.
- C. This medicine will cure the herpes infection.
- D. If the blisters come back, I will start taking the pills immediately.
Correct Answer: D
Rationale: Acyclovir reduces symptoms and recurrence of herpes but does not cure it. Starting treatment at recurrence is appropriate.
A client with anemia has a new prescription for ferrous sulfate. In teaching the client about diet and iron supplements, the nurse should emphasize that absorption of iron is enhanced if taken with which substance?
- A. Acetaminophen
- B. Orange juice
- C. Low fat milk
- D. An antacid
Correct Answer: B
Rationale: Orange juice. Ascorbic acid enhances the absorption of iron.