Nokea
The 3-year-old with LTB is receiving aerosolized racemic epinephrine. Which assessment finding should the nurse recognize as indicating that the treatment is having an adverse effect?
- A. Heart rate of 180 beats/min
- B. Blood pressure of 60/40 mm Hg
- C. Respiratory rate of 25 breaths/min
- D. Pulse oximetry of 90% on room air
Correct Answer: A
Rationale: A: Tachycardia is an adverse effect of racemic epinephrine (AsthmaNefrin). B: Hypertension, not hypotension, is an adverse effect of racemic epinephrine; a BP of 60/40 mm Hg in a 3-year-old indicates hypotension. C: A respiratory rate of 25 breaths/min is normal for a 3-year-old. D: A pulse oximetry reading of 90% is concerning and may indicate the need for supplemental oxygen, but it is not an adverse effect from the medication.
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The nurse is preparing to administer IV fluids to the 13-kg child who has dehydration. The daily IV fluid requirement is to administer 1000 mL / 50 mL/kg over 10 kg. How many milliliters per hour should the nurse calculate to administer the IV therapy correctly?
Correct Answer: 48
Rationale: This child weighs 13 kg; the daily requirement is 1000 mL + (50 mL x 3) = 1150 mL/24 hr. The hourly rate is 1150 mL/ 24 hr = 47.9167 mL/hr, rounded to 48 mL/hr.
The client is started on citalopram for treatment of depression. Which information is most important for the nurse to include when teaching the client?
- A. Activity levels should be increased to include a daily exercise routine.
- B. If sexual side effects become unbearable, consult your health care provider.
- C. Taking St. John's wort with your citalopram can enhance its effectiveness.
- D. Take your blood pressure every morning and report Ascertain any significant changes.
Correct Answer: B
Rationale: Sexual dysfunction is a common side effect associated with the use of SSRIs; the client taking citalopram (Celexa), an SSRI, should consult the HCP if having unbearable sexual side effects.
The nurse should teach a client in the Emergency Department, who has suffered an ankle sprain, to:
- A. Use cold applications to the sprain during the first 24-48 hours
- B. Expect disability to decrease within the first 24 hours of injury
- C. Expect pain to decrease within 3 hours after injury
- D. Begin progressive passive and active range of motion exercises immediately
Correct Answer: A
Rationale: Cold applications reduce edema and vasoconstriction in the first 24-48 hours of an ankle sprain. Pain and disability may increase initially, and exercises begin later per physician guidance.
The newly hospitalized client admits using heroin 8 hours ago. Which assessment findings, if observed in the client, should the nurse associate with heroin withdrawal?
- A. Mental confusion, drowsiness, and hypotension
- B. Dysphoric mood, pupillary dilation, and sweating
- C. Pinpoint pupils, constipation, and urinary retention
- D. No withdrawal signs until 2 to 3 days have passed
Correct Answer: B
Rationale: Dysphoric mood, pupillary dilation, and sweating are signs of heroin withdrawal. Heroin is an opioid.
The client is taking methylphenidate sustained-release tablets once daily for attention deficit disorder. The medication peaks in 4 to 7 hours and has a duration of 12 hours. At which time should the nurse instruct the client to take the prescribed dose of methylphenidate?
- A. At bedtime
- B. With the midday meal
- C. Six hours before bedtime
- D. Upon waking in the morning
Correct Answer: D
Rationale: Sustained-release methylphenidate (Ritalin) should be taken in the morning to avoid sleep interference.