Nokea
The nurse administered phenylephrine eye drops to the client before performing an ophthalmoscopic eye examination. Which assessment finding should the nurse expect?
- A. Tremor
- B. Hypotension
- C. Pupil miosis
- D. Pupil mydriasis
Correct Answer: D
Rationale: A: Tremors are a side effect if phenylephrine is absorbed systemically. B: Because phenylephrine absorbed systemically is a vasoconstrictor, hypertension (not hypotension) can occur as a side effect. C: Miosis is pupil constriction, not an effect of phenylephrine. D: Phenylephrine (NeoSynephrine), an adrenergic agonist, produces pupil dilation (mydriasis) by activating alpha1-adrenergic receptors on the dilator muscles of the iris.
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Six months after starting disulfiram for treatment of alcoholism, the client has serum laboratory tests completed (see exhibit). Place an X on each serum laboratory result that the nurse should report immediately to the HCP.
- A. Potassium
- B. Albumin
- C. AST
- D. ALT
- E. Total bilirubin
- F. Alkanine Phosphatase
- G. RBCs
Correct Answer: B,C,DE,F
Rationale: Abnormal liver function tests (low albumin, elevated AST, ALT, total bilirubin, ALP) should be reported due to disulfiram's potential liver effects. [Image-based question; X on abnormal LFTs.]
The nurse is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?
- A. I am nervous about how painful labor will be.
- B. I need to review my finances and make sure I am prepared to care for a child.
- C. I hate this nausea that I've been having for a week.
- D. I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent.
Correct Answer: D
Rationale: The nurse should follow up on the client's lack of support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea.
The client taking carbamazepine XR for seizure control reports that pieces of the medication are being passed into the stool. Which action by the nurse is most important?
- A. Report this to the health care provider.
- B. Reassure the client that this is normal.
- C. Collect the stool for laboratory analysis.
- D. Document the findings in the medical record.
Correct Answer: B
Rationale: A: It is inappropriate to report an expected finding to the HCP. B: Carbamazepine XR (Tegretol XR) is a sustained-release medication with a coating that is not absorbed but is excreted in feces and may be visible in stool. The nurse should reassure the client that this is normal. C: Collecting the stool for laboratory analysis is not necessary because the coating is not absorbed but excreted in the stool. D: The nurse should document the client teaching but usually would not document the presence of the coating in the client's stool.
The major electrolytes in the extracellular fluid are:
- A. potassium and chloride.
- B. potassium and phosphate.
- C. sodium and chloride.
- D. sodium and phosphate.
Correct Answer: C
Rationale: Sodium and chloride are the major electrolytes in the extracellular fluid.
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.