Nokea
The nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which intervention is most appropriate to prevent toxicity?
- A. Monitor respiratory rate
- B. Assess deep tendon reflexes
- C. Measure urine output
- D. All of the above
Correct Answer: D
Rationale: Magnesium sulfate toxicity can cause respiratory depression loss of reflexes and reduced urine output. Monitoring respiratory rate reflexes and urine output is essential to detect toxicity early and ensure patient safety.
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The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which toxic effects of this drug would be reported to the physician immediately?
- A. Rales and distended neck veins
- B. Red discoloration of the urine
- C. Nausea and vomiting
- D. Elevated BUN and dry, flaky skin
Correct Answer: A
Rationale: Rales and distended neck veins suggest cardiotoxicity (e.g., heart failure), a serious doxorubicin side effect requiring immediate reporting. Red urine (B) is expected, nausea/vomiting (C) are common, and BUN/skin changes (D) are less urgent.
The nurse is caring for a client with a history of schizophrenia. The nurse should expect the client to have:
- A. Hallucinations
- B. Memory loss
- C. Tremors
- D. Joint pain
Correct Answer: A
Rationale: Schizophrenia is characterized by hallucinations, delusions, and disorganized thinking, with hallucinations being a common symptom.
The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release?
- A. Norepinephrine (Levophed)
- B. Dobutamine (Dobutrex)
- C. Propranolol (Inderal)
- D. Epinephrine (Adrenalin)
Correct Answer: D
Rationale: Norepinephrine's side effects are primarily related to safe, effective care environment and include decreased peripheral perfusion and bradycardia. Dobutamine's side effects include increased heart rate and blood pressure, ventricular ectopy, nausea, and headache. Propranolol's side effects include elevated blood urea nitrogen, serum transaminase, alkaline phosphatase, and lactic dehydrogenase. Epinephrine increases serum glucose levels by increasing glycogenolysis and inhibiting insulin release. Prolonged use can elevate serum lactate levels, leading to metabolic acidosis, increased urinary catecholamines, false elevation of blood urea nitrogen, and decreased coagulation time.
While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?
- A. Discontinue the central line.
- B. Begin a peripheral IV.
- C. Document in the nurse's notes and notify the physician after redressing the site.
- D. Clean the site well and redress.
Correct Answer: C
Rationale: The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued.
The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:
- A. Mix the insulin with Dextrose 5% in water.
- B. Flush the IV tubing with the insulin solution and discard the first 50 mL.
- C. Give the insulin without diluting.
- D. Add the insulin to a solution of normal saline.
Correct Answer: D
Rationale: Regular insulin for IV infusion should be diluted in normal saline to ensure compatibility and prevent adsorption to IV tubing. Dextrose is inappropriate during DKA, and flushing with insulin wastes medication.