Nokea
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion.
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
- D. Obtain the first unit of packed RBCs from the blood bank.
- E. Start an IV bolus of lactated Ringer's solution.
Correct Answer: B
Rationale: [0, 1, 0, 0]
The correct answer is Stay with the client for the first 15 min of the transfusion. This action is indicated to monitor for adverse reactions such as fever, chills, or signs of hemolysis. Documenting the blood product transfusion (A) is important but not a priority during the initial phase. Titrating the infusion rate (C) and obtaining the blood product (D) are essential, but staying with the client for monitoring takes precedence. Starting an IV bolus (E) is not related to blood transfusion monitoring.
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A nurse is discussing adverse reactions to pain medications in older adult clients with a newly licensed nurse. Which of the following findings should the nurse include as risk factors for an adverse drug reaction? (SATA)
- A. Polypharmacy
- B. Increased rate of absorption
- C. Decreased percentage of body fat
- D. Multiple health problems
Correct Answer: A,C,D,E
Rationale: To determine risk factors for adverse drug reactions in older adults, consider the following:
A: Polypharmacy increases the likelihood of drug interactions and adverse effects.
C: Decreased body fat can affect drug distribution, leading to higher drug concentrations.
D: Multiple health problems may require multiple medications, increasing the risk of adverse reactions.
E: Age-related changes in liver and kidney function can affect drug metabolism and excretion.
Other choices are incorrect because increased rate of absorption does not necessarily increase risk and choices F and G were not provided.
A nurse is instructing a client who has a new prescription for a daily dose of lovastatin extended-release. Which of the following information should the nurse include in the teaching?
- A. You will need liver function tests before beginning therapy.
- B. Avoid consuming dairy products while taking this medication.
- C. You may crush the medication and mix it with applesauce.
- D. You should take the medication in the morning.
Correct Answer: A
Rationale: The correct answer is A: You will need liver function tests before beginning therapy. This is important because lovastatin, a statin medication, can potentially cause liver damage. Liver function tests are necessary to monitor for any signs of liver toxicity. Choice B is incorrect because there is no specific interaction between lovastatin and dairy products. Choice C is incorrect as lovastatin extended-release should not be crushed as it may affect its effectiveness. Choice D is incorrect as there is no specific time of the day required to take lovastatin.
A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following as an indication of an allergic reaction following the injection?
- A. Urticaria
- B. Bradycardia
- C. Pallor
- D. Dyspepsia
Correct Answer: A
Rationale: The correct answer is A: Urticaria. Urticaria, or hives, is a classic sign of an allergic reaction. It presents as raised, red, itchy welts on the skin. This occurs due to histamine release in response to the allergen (penicillin in this case). Monitoring for urticaria is crucial as it indicates a potentially serious allergic reaction that may progress to anaphylaxis. Bradycardia (B), Pallor (C), and Dyspepsia (D) are not typically associated with allergic reactions to penicillin. Bradycardia is a slow heart rate, pallor is paleness of the skin, and dyspepsia is indigestion. These symptoms are more likely related to other conditions or side effects rather than an allergic reaction.
A nurse is teaching a client about oral contraceptive. Which of the following information should the nurse include in the teaching?
- A. Abdominal pain is an expected adverse effect of oral contraceptives
- B. It can take up to 1 year to become pregnant after stopping an oral contraceptive
- C. Some herbal supplements can decrease the effectiveness of an oral contraceptive
- D. A pelvic examination is needed prior to starting an oral contraceptive
Correct Answer: C
Rationale: The correct answer is C: Some herbal supplements can decrease the effectiveness of an oral contraceptive. The nurse should include this information in the teaching to ensure the client understands potential interactions. Herbal supplements like St. John's Wort can reduce the effectiveness of oral contraceptives by increasing their metabolism. This can lead to contraceptive failure and unintended pregnancy. Option A is incorrect because abdominal pain is not an expected adverse effect of oral contraceptives. Option B is incorrect as fertility typically returns quickly after stopping oral contraceptives, not taking up to a year. Option D is incorrect as a pelvic examination is not always necessary before starting oral contraceptives.
A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following should the nurse identify as an adverse effect of this medication?
- A. Hypoglycemia
- B. Bradycardia
- C. Red man syndrome
- D. Hypotension
Correct Answer: D
Rationale: The correct answer is D: Hypotension. Phenytoin can cause hypotension as an adverse effect due to its vasodilatory properties. The drug can cause a decrease in blood pressure, leading to symptoms such as dizziness and lightheadedness. This adverse effect is important for the nurse to recognize as it can potentially lead to complications such as falls in the client.
A: Hypoglycemia is not a common adverse effect of phenytoin.
B: Bradycardia is not a typical adverse effect of phenytoin.
C: Red man syndrome is associated with vancomycin, not phenytoin.
Summary: Phenytoin is more likely to cause hypotension as an adverse effect, rather than hypoglycemia, bradycardia, or red man syndrome.