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The nurse is assessing the client to update the plan of care.Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. "The nurse determines that the client's is experiencing -----------, and the blood pressure changes are the result of-------------------.
- A. Adverse drug reaction
- B. Antibiotic
- C. Syncope
- D. Heart failure
- E. IV infiltration
Correct Answer: A,B
Rationale: The client’s symptoms (dizziness, hives, etc.) indicate an adverse reaction (Red Man Syndrome) to vancomycin, causing hypotension. Both blanks are correctly filled by 'Adverse drug reaction' and 'Antibiotic' (vancomycin).
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A client with a cold is taking the antitussive medication benzonatate. Which assessment information indicates to the nurse that the medication is effective?
- A. Denies having coughing spells.
- B. Able to sleep through the night.
- C. Expectorating bronchial secretions.
- D. Reports reduced nasal discharge.
Correct Answer: B
Rationale: Benzonatate suppresses cough, and sleeping through the night indicates effective cough control. Denying coughing spells is less specific, expectoration relates to expectorants, and nasal discharge is unrelated to antitussive effects.
A client with peptic ulcer disease is scheduled to receive doses of pantoprazole IV and sucralfate PO before breakfast at 0730. The client reports experiencing heartburn when the nurse brings the scheduled medications. Which action should the nurse take?
- A. Hold the dose of IV pantoprazole until the client has finished eating breakfast.
- B. Provide a PRN dose of antacid along with the scheduled medications.
- C. Instruct the client to take the dose of sucralfate PO while eating breakfast.
- D. Administer both of the medications before breakfast as scheduled.
Correct Answer: D
Rationale: Pantoprazole and sucralfate should be administered before breakfast to maximize acid suppression and ulcer protection. Delaying pantoprazole reduces efficacy, antacids interfere with sucralfate absorption, and sucralfate requires an empty stomach.
Levothyroxine sodium is prescribed for a client with hypothyroidism. The nurse should instruct the client to report which symptom because it indicates that the client is taking too much levothyroxine sodium?
- A. Constipation.
- B. Decreased appetite.
- C. Restlessness.
- D. Intolerance to cold.
Correct Answer: C
Rationale: Restlessness indicates hyperthyroidism, suggesting excessive levothyroxine. Constipation, decreased appetite, and cold intolerance are hypothyroidism symptoms, not overdose.
An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HTN), is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments should the nurse include in evaluating the effectiveness of the medications? (Select all that apply.)
- A. Bowel sounds.
- B. Daily weight.
- C. Heart sounds.
- D. Blood pressure.
- E. Range of motion.
Correct Answer: B,C,D
Rationale: B: Daily weight monitors fluid retention (furosemide effectiveness). C: Heart sounds assess heart failure control (atenolol, enalapril). D: Blood pressure evaluates hypertension management (atenolol, enalapril). Bowel sounds and range of motion are unrelated to these medications’ effects.
Which laboratory value should the nurse review prior to administering the initial dose of a statin medication?
- A. Serum liver enzymes.
- B. Complete blood count.
- C. Serum electrolytes.
- D. Capillary blood glucose.
Correct Answer: A
Rationale: Statins can affect liver function, so reviewing serum liver enzymes is critical to monitor for hepatic adverse effects before initiation. CBC, electrolytes, and glucose are less directly related.