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The nurse is administering Penicillin to a patient who has tested positive for strep throat. The nurse knows to look for which of the following adverse e昀昀ects as a sign of an acute allergic reaction?
- A. blurred vision
- B. tinnitus
- C. skin rash/hives
- D. vomiting
Correct Answer: C
Rationale: An acute allergic reaction to Penicillin can present with symptoms such as skin rash or hives. This is a common sign of an allergic reaction and can indicate the patient is having an adverse response to the medication. It is essential for the nurse to monitor the patient closely for any signs of allergic reactions, including hives, as they can quickly progress to more severe reactions such as anaphylaxis. Other adverse effects listed in the choices, such as blurred vision, tinnitus, and vomiting, are not typically associated with an acute allergic reaction to Penicillin.
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When a patient is experiencing digoxin toxicity, which clinical situation would necessitate the use
- A. ? (Select all that apply.)
- B. The patient reports seeing colorful halos around lights.
- C. The patient™s serum potassium level is above 5 mEq/L.
- D. The patient is experiencing nausea and anorexi
Correct Answer: D
Rationale: When a patient is experiencing digoxin toxicity, severe sinus bradycardia that does not respond to cardiac pacing is a clinical situation that would necessitate the use of digoxin-specific antibody fragments (Digibind). This intervention is required to counteract the toxic effects of digoxin on the heart, especially in cases of severe bradycardia that can compromise cardiac output and lead to serious consequences. In this scenario, Digibind works by binding to digoxin molecules, thereby neutralizing their effects and helping to restore normal cardiac function.
A patient is scheduled to receive chemotherapy drugs that will cause myelosuppression. Which action by the nurse will be most important?
- A. Monitor for a change in temperature.
- B. Evaluate gastrointestinal function.
- C. Assess for evidence of cardiac compromise.
- D. Question the patient about changes in sense of taste.
Correct Answer: A
Rationale: Myelosuppression, a common side effect of chemotherapy, leads to a decrease in white blood cells, red blood cells, and platelets. A drop in white blood cells, particularly neutrophils, increases the risk of infection. Monitoring for a change in temperature is critical because fever is often the first sign of infection in neutropenic patients. Early detection allows for prompt intervention, such as administering antibiotics, to prevent life-threatening complications. While gastrointestinal function, cardiac compromise, and changes in taste are important to assess, they are not as immediately life-threatening as an undetected infection in a myelosuppressed patient.
What nursing interventions should you do when a patient is on Albuterol (select all that apply)
- A. Assess lung sounds , Pulse , and Blood pressure before administering
- B. Monitor for changes in behavior
- C. Observe for paradoxical bronchospasms
- D. Assess for abdominal distention
Correct Answer: A
Rationale: A. Assess lung sounds, Pulse, and Blood pressure before administering: It is important to assess the patient's baseline lung sounds, pulse rate, and blood pressure before administering Albuterol to monitor for any changes that may occur after administration. This is crucial in determining the effectiveness of the medication and detecting any potential side effects.
A patient has been started on therapy of a continuous infusion of lidocaine after receiving a loading dose of the drug. The nurse will monitor the patient for which adverse effect?
- A. Drowsiness
- B. Nystagmus
- C. Dry mouth
- D. Convulsions
Correct Answer: D
Rationale: Lidocaine is a local anesthetic that can have systemic effects if levels become toxic. Continuous infusion of lidocaine can lead to lidocaine toxicity, which can manifest as adverse effects including convulsions, altered mental status, confusion, seizures, and cardiac arrhythmias. Monitoring for signs of lidocaine toxicity, such as convulsions, is crucial when a patient is receiving continuous lidocaine infusion. It is important for the nurse to closely monitor the patient's neurological status and vital signs to promptly recognize and manage any adverse effects.
The nurse is caring for a young patient with a closed head injury who has an intracranial pressure of 35 (normal <20) and serum osmolality of 330 mOsm/kg. The nurse would anticipate which action?
- A. Administration of mannitol
- B. Withholding mannitol at this time, but taking other measures to reduce intracranial pressure
- C. Administration of sodium nitroprusside
- D. Taking no action at this time because the patient has a serum osmolality of 330, which will offset the effects of the elevated intracranial pressure
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic used to reduce intracranial pressure (ICP) by drawing fluid out of the brain tissue. However, it should be used cautiously in patients with elevated serum osmolality, as it can exacerbate hyperosmolality and lead to renal failure or other complications. In this case, the patient's serum osmolality is already high (330 mOsm/kg), so mannitol should be withheld, and other measures to reduce ICP, such as elevating the head of the bed, maintaining proper oxygenation, and avoiding hypercapnia, should be prioritized. Sodium nitroprusside (C) is used for hypertension, not ICP, and taking no action (D) is inappropriate given the elevated ICP.