Nokea
The nurse is caring for assigned clients. After administering prescribed medications, the nurse should immediately intervene if the client reports
- A. nausea during an infusion of amphotericin B.
- B. palpitations after receiving rapid-acting insulin.
- C. drowsiness after receiving fentanyl.
- D. itching in the perineal area while receiving intravenous dexamethasone.
Correct Answer: B
Rationale: Palpitations after rapid-acting insulin (B) suggest hypoglycemia or an adverse reaction, requiring immediate intervention to assess and stabilize. Nausea with amphotericin B (A), drowsiness with fentanyl (C), and itching with dexamethasone (D) are expected side effects and less urgent.
You may also like to solve these questions
The registered nurse (RN) observes licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply.
- A. Irrigates an indwelling catheter with warm tap water.
- B. Administers glargine insulin for a client with nothing by mouth (NPO) status.
- C. Obtains a 12-lead electrocardiogram for a client with hyperkalemia.
- D. Clamps a chest tube while the client ambulates.
- E. Repositions a client who requires log rolling by using a gait belt.
Correct Answer: A, B, D, E
Rationale: Irrigating with tap water (A) risks infection, insulin for NPO client (B) risks hypoglycemia without RN assessment, clamping a chest tube (D) risks pneumothorax, and using a gait belt for log rolling (E) is incorrect technique. ECG (C) is within LPN scope.
The nurse has completed medication administration to assigned clients. The nurse should initially follow up on the client who received prescribed
- A. mirtazapine and reports sleepiness.
- B. citalopram and reports nausea.
- C. fluphenazine and reports fever.
- D. clonidine and reports dizziness while rolling over in bed.
Correct Answer: C
Rationale: Fever after fluphenazine (C) suggests neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Sleepiness with mirtazapine (A), nausea with citalopram (B), and dizziness with clonidine (D) are expected side effects and less urgent.
The nurse has been made aware of the following client situations. The nurse should first assess the client
- A. who recently received tissue plasminogen activator (tPA) and has oozing at the insertion site of the peripheral vascular access device.
- B. who has acute kidney injury (AKI) and has voided 100 mL of urine in the past six hours.
- C. who has pericarditis and is sitting upright in the bed, leaning forward to help relieve the chest pain.
- D. has an intractable migraine headache and has vomited twice in the past two hours.
Correct Answer: A
Rationale: Oozing at the tPA insertion site (A) suggests bleeding risk, a critical complication due to thrombolytic therapy, requiring immediate assessment. Oliguria in AKI (B), pericarditis pain relief (C), and migraine with vomiting (D) are less urgent.
A nurse is working in a busy medical-surgical unit and has received report on the following four clients. The nurse should first see the client with
- A. A client who underwent surgery yesterday and is complaining of incisional pain at a level of 8/10
- B. new-onset atrial fibrillation who is complaining of chest pain.
- C. diabetes who has a foot wound that appears infected and an oral temperature of 100.4°F (38°C)
- D. advanced Alzheimer's disease who is confused and has had a recent fall.
Correct Answer: B
Rationale: New-onset atrial fibrillation with chest pain (B) suggests possible cardiac ischemia, a life-threatening emergency requiring immediate assessment. Severe pain (A), infected foot wound (C), and confusion post-fall (D) are urgent but less immediately life-threatening.
The nurse is triaging phone calls for the primary healthcare provider (PHCP). Which client situation requires immediate notification to the PHCP?
- A. A client with heart failure that reports an overnight weight gain of three pounds.
- B. A client with peritoneal dialysis who has not had a bowel movement in two days.
- C. A client with irritable bowel syndrome (IBS) that reports frequent diarrhea.
- D. A client with nephrolithiasis that reports bloody urine and flank pain.
Correct Answer: A
Rationale: Rapid weight gain of three pounds overnight in heart failure (A) indicates fluid overload, a potential precursor to acute decompensation, requiring immediate PHCP notification. Constipation in peritoneal dialysis (B), frequent diarrhea in IBS (C), and hematuria with flank pain in nephrolithiasis (D) are concerning but less immediately life-threatening.