Nokea
The nurse is reviewing documentation on four clients prior to administering medications. The nurse should immediately withhold the medication and notify the HCP about which client?
- A. Client 1
- B. Client 2
- C. Client 3
- D. Client 4
Correct Answer: D
Rationale: Client 4's symptoms of tardive dyskinesia (lip smacking, uncontrolled rhythmic movements) may be irreversible, requiring immediate medication withdrawal and HCP notification.
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The nurse is preparing to administer a pm dose of benztropine to the client with worsening akathisia. The client's medication record lists benztropine 0.5 mg IM q4h pm. The vial contains 1 mg/mL. How many milliliters of the medication should the nurse administer?
Correct Answer: 0.5
Rationale: Calculation: 0.5 mg/ 1 mg/mL = 0.5 mL.
The 17-year-old female is about to have a drug screen test for employment. The adolescent tells the nurse of a recent UTI that was treated with antibiotics. Which antibiotic, if identified by the client, could produce a false-positive urine screening test for opioids?
- A. Cephalexin
- B. Ceftazidime
- C. Amoxicillin
- D. Ciprofloxacin
Correct Answer: D
Rationale: A: Cephalexin (Keflex) does not interfere with urine testing for opioids. B: Ceftazidime (Fortaz), a cephalosporin, does not interfere with urine testing for opioids. C: Amoxicillin (Amoxil), an aminopenicillin, does not interfere with urine testing for opioids. D: Fluoroquinolones, such as ciprofloxacin (Cipro), can cause false-positive urine opiate screens.
The client's dose of mirtazapine was increased from 15 to 30 mg at bedtime two days ago. When the nurse is preparing to administer mirtazapine, the client reports having insomnia, irritability, and panic attacks. What should the nurse do next?
- A. Document the symptoms, hold the dose, and notify the HCP.
- B. Telephone the HCP to request a pm sedative to help the client sleep.
- C. Have the client participate in a card game with other clients on the unit.
- D. Reassure the client that these symptoms will subside after taking this dose.
Correct Answer: A
Rationale: Mirtazapine (Remeron) is an antidepressant. Adverse effects include insomnia, irritability, panic attacks, and suicidal ideation. A change in medication may be needed rather than a dosage increase.
The nurse is teaching the parent of the 3-year-old being treated with vincristine sulfate for Wilms' tumor. The nurse should inform the parents to immediately notify the HCP of which most significant adverse effect?
- A. The child develops diarrhea.
- B. The child's hair begins to fall out.
- C. The child develops dysphagia and paresthesia.
- D. The child has signs or symptoms of depression.
Correct Answer: C
Rationale: A: Both diarrhea and severe constipation are adverse effects of vincristine, and prophylactic treatment is implemented at the beginning of therapy to decrease the potential of these occurring. B: Hair loss is a common adverse reaction to the medication and is reversible. C: Dysphagia and paresthesia are CNS adverse effects from vincristine sulfate (Oncovin). The nurse should teach the parent to notify the HCP immediately if these occur. D: Three-year-olds may not show signs or symptoms of depression. If present, the signs and symptoms should be distinguished as being associated with the neoplastic disease itself or as side effects of the medication.
The client is being treated with Clozapine. Which findings during the nurse's assessment indicate that the client is experiencing adverse effects of Clozapine? Select all that apply.
- A. Dehydration
- B. Agranulocytosis
- C. Increasing anxiety
- D. Extreme salivation
- E. Blood glucose 192 mg/dL
Correct Answer: B,D,E
Rationale: Agranulocytosis, hypersalivation, and hyperglycemia are adverse effects of clozapine (Clozaril).