Nokea
The nurse is caring for a client with a history of seizures who is receiving phenytoin (Dilantin) 100 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I brush my teeth twice a day.
- B. I take my medication with milk.
- C. I have a rash on my arms.
- D. I feel drowsy in the morning.
Correct Answer: C
Rationale: A rash may indicate a hypersensitivity reaction to phenytoin, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate evaluation. Options A, B, and D are less concerning: brushing teeth is routine, milk does not affect absorption, and drowsiness is a common side effect.
You may also like to solve these questions
A nurse is performing the routine daily cleaning of a tracheostomy. During the procedure, the client coughs and displaces the tracheostomy tube. This negative outcome could have been avoided by
- A. placing an obturator at the client's bedside
- B. having another nurse assist with the procedure
- C. fastening clean tracheostomy ties before removing old ties
- D. placing the client in a flat, supine position
Correct Answer: C
Rationale: fastening clean tracheostomy ties before removing old ties. Fastening clean tracheostomy ties before removing old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is coughed out. A second nurse is not needed. Changing the position may not prevent a dislodged tracheostomy.
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
- A. Determine whether the ear infection has affected her hearing.
- B. Determine whether she needs a tympanoplasty.
- C. Document that the infection has completely cleared.
- D. Obtain a new prescription in case the infection recurs.
Correct Answer: C
Rationale: A recheck confirms the otitis media has cleared, preventing complications. Hearing tests or tympanoplasty are not routine, and new prescriptions are unnecessary unless recurrence occurs.
The nurse is to obtain pedal pulses on a client following a cardiac catheterization. Which is the proper procedure?
- A. Place the fingertips against the wrist bone.
- B. Place the stethoscope over the apex of the heart.
- C. Place the fingertips against the side of the neck.
- D. Place the fingertips on top of the foot.
Correct Answer: D
Rationale: Pedal pulses are assessed by palpating the dorsalis pedis or posterior tibial arteries on the foot, checking for circulation post-catheterization.
A 56-year-old woman is receiving digoxin (Lanoxin) 0.25 mg PO qd and furosemide (Lasix) 40 mg PO bid. She calls her physician for complaints of mild diarrhea. The physician prescribes Kaopectate 60 mg after each bowel movement for 2 days and instructs her to call back if symptoms don't subside.
The nurse should instruct the woman to
- A. make no changes in her medication schedule.
- B. wait 1 hour before taking her scheduled medications if she takes the Kaopectate.
- C. hold her scheduled medications until the diarrhea subsides.
- D. take the Lanoxin but hold the Lasix if she takes the Kaopectate.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) PO meds would be absorbed by Kaopectate not by stomach (2) correct-Kaopectate absorbs PO meds, separate administration of other meds (3) other meds should be given later (4) both meds should be given later
A 69-year-old man is receiving dexamethasone (Decadron) 3 mg PO TID for chronic lymphocytic leukemia. It is MOST important for the nurse to report which of the following findings to the physician?
- A. PT 12 seconds and Hgb 15 g/dL.
- B. BUN 18 mg/dL and creatinine 1.0 mg/dL.
- C. K⺠3.4 mEq/L and CA⺠5/5 mEq/L.
- D. AST (SGOT) 18 U/L and ALT (SGPT) 12 U/L.
Correct Answer: C
Rationale: normal Kâ 3.5-5.0 mEq/L, normal Ca 4.5-5.3 mEq/L, indicates hypokalemia and hypercalcemia