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The client with chronic, stable angina telephones the clinic nurse and reports a headache lasting for several days after taking one dose of isosorbide mononitrate. The client also reports symptoms of orthostatic hypotension and palpitations. Which is the nurse's best action?
- A. Recommend that the client make an appointment with the health care provider.
- B. Have the client retime the dose for a later time when the client is more active.
- C. Instruct the client to take two acetaminophen 325-mg tablets with the next dose.
- D. Teach Immaculate that the headaches will subside over time with continued use.
Correct Answer: A
Rationale: A: Severe headaches, orthostatic hypotension, and palpitations may be a sign of isosorbide mononitrate (Imdur) toxicity; thus, the client should be evaluated by an HCP. Other signs of toxicity include syncope, dizziness, blurred vision, and light-headedness. B: Isosorbide mononitrate should be taken in the morning to improve blood flow to the heart and prevent angina attacks that can occur due to increased oxygen demand from activity. C: A headache (but not a severe headache) can be treated with or prevented by analgesics taken either before or at the same time as the isosorbide mononitrate. D: Although the headaches will subside over time, the client is experiencing symptoms of isosorbide mononitrate toxicity.
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The client taking paroxetine telephones the mental health clinic nurse and states, “Since I started taking St. John's wort, I have had a high fever and muscle stiffness, and I am sweating a lot.†Which statement is most appropriate?
- A. You may have the flu; call your primary provider to make an appointment.
- B. Take ibuprofen, drink fluids, and rest; call tomorrow if the symptoms worsen.
- C. Could you have doubled up on your medication, taking more than prescribed?
- D. You should be taken to the emergency department right away to be evaluated.
Correct Answer: D
Rationale: Fever, muscle stiffness (rigidity), and diaphoresis are symptoms of serotonin syndrome, a potentially fatal condition that may occur with concurrent use of St. John's wort and paroxetine (Paxil). The client should be taken to the ED.
The nurse is assessing an 18-month-old. Which of these statements made by the parent or caregiver would require follow-up?
- A. I'm worried that my child is not using two-word phrases yet.
- B. My child has recently taken a few steps but does not seem stable when standing.
- C. My child seems to have developed separation anxiety when I leave.
- D. I'm letting my child use a spoon to eat.
Correct Answer: B
Rationale: Around 12 months of age, children should have taken their first steps and stand well. If a child hasn't made progress by 18 months old, a physical therapy evaluation may be necessary. At 18 months, the child should be using a spoon to eat. However, two-word phrases are not expected until 2 years. Separation anxiety is expected between 6 and 18 months.
The nurse is preparing to administer Azithromycin, and the pharmacy has provided the drug in a powder form that requires reconstitution connected to a saline piggyback. Which of the following is least concerning when preparing the medication?
- A. The expiration date on the powder vial is the same as the current date.
- B. The brand/trade name is not listed on the vial.
- C. The storage instructions on the vial says 'store at room temperature', and the vial is very cold to the touch indicating it has been taken out of a freezer.
- D. The bag of saline is leaking.
Correct Answer: B
Rationale: The brand or trade name is not required to be on the medication label if the generic name is present. The nurse should check that the medication is not expired and that it has been stored according to the storage instructions. If the saline bag is leaking, it may indicate that the container is damaged and the fluid may not be sterile.
A serious complication of a total hip replacement is displacement of the prosthesis. What is the primary sign of displacement?
- A. pain on movement and weight bearing
- B. hemorrhage
- C. affected leg appearing 1-2 inches longer
- D. edema in the area of the incision
Correct Answer: A
Rationale: Pain on movement and weight bearing indicates pressure on the nerves or muscles caused by the dislocation. Other symptoms of dislocation include an inability to bear weight and a shortening of the affected leg. Edema is not a primary sign of displacement.
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.