The nurse is assessing a client who is being treated with a beta-adrenergic blocker. Which assessment findings would indicate that the client may be experiencing dose-related side effects of the medication? Select all that apply.
- A. Dizziness
- B. Bradycardia
- C. Chest pain
- D. Reflex tachycardia
- E. Sexual dysfunction
- F. Cardiac dysrhythmias
Correct Answer: A,B,E
Rationale: Beta-adrenergic blockers, commonly called beta blockers, are useful in treating cardiac dysrhythmias, mild hypertension, mild tachycardia, and angina pectoris. Side effects commonly associated with beta blockers are usually dose related and include dizziness (hypotensive effect), bradycardia, hypotension, and sexual dysfunction (impotence). Options 3, 4, and 6 are reasons for prescribing a beta blocker; however, these are general side effects of alpha-adrenergic blockers.
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A nursing childbirth educator tells a class of expectant parents that it is standard routine to instill the ophthalmic ointment form of which medication into the eyes of a newborn infant as a preventive measure against ophthalmia neonatorum?
- A. Penicillin
- B. Neomycin
- C. Vitamin K
- D. Erythromycin
Correct Answer: D
Rationale: Ophthalmic erythromycin 0.5% ointment is a broad-spectrum antibiotic and is used prophylactically to prevent ophthalmia neonatorum, an eye infection acquired from the newborn infant's passage through the birth canal. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against Neisseria gonorrhoeae and Chlamydia trachomatis. Vitamin K is administered in an injectable form to the newborn infant to prevent abnormal bleeding, and it promotes liver formation of the clotting factors II, VII, IX, and X. Options 1 and 2 are incorrect and are not medications routinely used in the newborn.
The nurse is performing an otoscopic examination on a client with a suspected diagnosis of mastoiditis. Which finding should the nurse expect to note if this disorder was present?
- A. A dull red tympanic membrane
- B. A mobile tympanic membrane
- C. A transparent tympanic membrane
- D. A pearly colored tympanic membrane
Correct Answer: A
Rationale: Otoscopic examination of a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Options 2, 3, and 4 indicate normal findings in an otoscopic examination.
A client who has experienced an acute kidney injury is prescribed a fluid restriction of 1500 mL per day. Which interventions will the nurse implement to assist the client in maintaining this restriction? Select all that apply.
- A. Removing the water pitcher from the bedside
- B. Using mouthwash with alcohol for mouth care
- C. Prohibiting beverages with sugar to minimize thirst
- D. Providing the client with lip balm to keep lips moist
- E. Offering the client ice chips at intervals during the day
Correct Answer: A,D,E
Rationale: The nurse can help the client maintain fluid restriction through a variety of means. The water pitcher should be removed from the bedside to aid in compliance. The use of ice chips and lip ointments is another intervention that may be helpful to the client on fluid restriction. Frequent mouth care is important; however, alcohol-based products should be avoided because they are drying to mucous membranes. Beverages that the client enjoys are provided and are not restricted based on sugar content.
A client diagnosed with acute pyelonephritis is scheduled for an intravenous pyelogram this morning. During report the nurse learns that the client vomited several times during the night and continues to report being nauseated. What intervention should the nurse implement to assure the client's safety regarding the scheduled procedure?
- A. Cancels the pyelogram
- B. Monitors the client closely for any additional vomiting
- C. Medicates the client with a standing order for metoclopramide
- D. Requests a prescription for a 0.9% saline intravenous infusion
Correct Answer: D
Rationale: The highest priority of the nurse would be to request a prescription for an intravenous infusion. This is needed to replace fluid lost with vomiting, will be necessary for dye injection for the procedure, and will assist with the elimination of the dye after the procedure. The cancelation of the procedure is premature. Neither monitoring nor medicating the patient with an antiemetic will address the fluid loss problem.
The nurse is assessing a client diagnosed with pleurisy 48 hours ago. When auscultating the chest the nurse is unable to detect the pleural friction rub, which was auscultated on admission. This change in the client's condition confirms which event has occurred?
- A. The prescribed medication therapy has been effective.
- B. The client has been taking deep breaths as instructed.
- C. The effects of the inflammatory reaction at the site decreased.
- D. There is now an accumulation of pleural fluid in the inflamed area.
Correct Answer: D
Rationale: Pleurisy is the inflammation of the visceral and parietal membranes. These membranes rub together during respiration and cause pain. Pleural friction rub is auscultated early in the course of pleurisy, before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears. Options 1, 2, and 3 are incorrect interpretations.
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