Nokea
The nurse is administering the following 1800 medications. Which medication should the nurse question before administering?
- A. The sliding-scale insulin to the client who has just been released to have the evening meal.
- B. The antibiotic to the client who is one (1) day postoperative exploratory abdominal surgery.
- C. Metformin (Glucophage), a biguanide, to the client having a CT scan with contrast dye in the morning.
- D. Protonix, a proton pump inhibitor, to the client diagnosed with peptic ulcer disease.
Correct Answer: C
Rationale: Metformin must be held before contrast dye due to lactic acidosis risk if renal function is impaired; other medications are appropriate.
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A client is receiving digitalis. The nurse should instruct the client to report which of the following side effects?
- A. Nausea, vomiting, fatigue
- B. Rash, dyspnea, edema
- C. Polyuria, thirst, dry skin
Correct Answer: A
Rationale: Nausea, vomiting, fatigue. Side effects of digitalis toxicity include fatigue, nausea, vomiting, anorexia, and bradycardia. Digitalis inhibits the sodium potassium ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac output.
A 13-month-old child is admitted to the emergency room with salicylate poisoning. Her mother found her beside the empty bottle of adult aspirin. She says there were 'about 10' aspirin left in the bottle. What manifestations would the nurse most expect to see in the child?
- A. Bradypnea and pallor
- B. Hyperventilation and hyperpyrexia
- C. Subnormal temperature and bleeding
- D. Melena and bradycardia
Correct Answer: B
Rationale: Salicylate poisoning causes metabolic acidosis, leading to hyperventilation, and stimulates the CNS, causing fever (hyperpyrexia).
A woman who is taking cortisone for an acute exacerbation of rheumatoid arthritis is upset about the fat face she has developed. She says to the nurse, 'I'm going to quit taking that cortisone.' The nurse's response should be based on which understanding?
- A. Cortisone does not cause a fat face.
- B. The symptoms will lessen as her body adjusts to the medication.
- C. The drug should be immediately discontinued when adverse effects occur.
- D. Cortisone should never be abruptly discontinued.
Correct Answer: D
Rationale: Abrupt discontinuation of cortisone can cause adrenal insufficiency; tapering is required to prevent complications.
A newly admitted client has a diagnosis of depression. She complains of 'twitching muscles' and a 'racing heart', and states she stopped taking Zoloft a few days ago because it was not helping her depression. Instead, she began to take her partner's Parnate. The nurse should immediately assess for which of these adverse reactions?
- A. Pulmonary edema
- B. Atrial fibrillation
- C. Mental status changes
- D. Muscle weakness
Correct Answer: C
Rationale: Mental status changes. Use of serotonergic agents may result in Serotonin Syndrome with confusion, nausea, palpitations, increased muscle tone with twitching muscles, and agitation. Serotonin syndrome is most often reported in patients taking 2 or more medications that increase CNS serotonin levels by different mechanisms. The most common drug combinations associated with serotonin syndrome involve the MAOIs, SSRIs, and the tricyclic antidepressants.
The male client comes to the emergency department and reports he stepped on a rusty nail at home about two (2) hours ago. Which question would be most important for the nurse to ask during the admission assessment?
- A. What have you used to clean the puncture site?
- B. Did you bring the nail with you so we can culture it?
- C. Do you remember when you had your last tetanus shot?
- D. Are you able to put any weight on your foot?
Correct Answer: C
Rationale: Tetanus risk is high with puncture wounds; knowing the last tetanus shot guides prophylaxis, the priority per CDC guidelines.