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The nurse is reviewing information for the 6-month-old who is being given ranitidine. Which finding should the nurse identify as an adverse effect of ranitidine?
- A. A heart rate of 110 bpm
- B. Oral temperature of 102.7°F (39.3°C)
- C. Spitting up some formula after each feeding
- D. A hard, pebble-like bowel movement every 2 days
Correct Answer: D
Rationale: A: An HR of 110 bpm is normal for a 6-month-old; the range is 80-170 bpm. B: Fever (temperature of 102.7°F) is not an adverse effect of ranitidine. C: Ranitidine is indicated for GERD; spitting up after feedings should improve. If not, then the medication dose may be too low or the medication itself ineffective. Spitting up is not a side effect. D: The nurse should identify that a hard, pebble-like bowel movement every 2 days demonstrates constipation; constipation is an adverse effect of ranitidine (Zantac).
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The nurse notes from the child's MAR illustrated that the child is to receive the first dose of a newly prescribed medication at 0800 hours. The drug reference book recommends an initial pediatric dose of lamotrigine of 0.6 mg/kg/day in two divided doses for the first 2 weeks. Which action by the nurse is most appropriate?
- A. Administer the medication as written on the MAR.
- B. Telephone the health care provider to question the dose.
- C. Ask the parent if this is the dose the child had been taking.
- D. Consult the pharmacist to verify whether the dose is correct.
Correct Answer: B
Rationale: A: Although the medication is written on the MAR, an error still exists in the dose, and the medication should not be administered. B: The nurse should notify the HCP. The child weighs 30 kg; the recommended initial daily dose of lamotrigine (Lamictal) for this child would be 18 mg (0.6 x 30 = 18 mg). If given 18 mg bid, the child would receive a daily dose of 36 mg, twice the recommended initial pediatric dose. C: The child has a new-onset seizure disorder; it is unlikely that the child was taking this medication prior to hospitalization. D: Consulting the pharmacist is unnecessary; the nurse still needs to seek clarification from the HCP.
The nurse teaches the client who has lesions that have not healed and are recurring about the newly prescribed medication ganciclovir. The nurse should document that teaching about ganciclovir was completed for the client with which illustrated condition?
- A. ganeiclovir_1.PNG
- B. ganeiclovir_2.PNG
- C. ganeiclovir_3.PNG
- D. ganeiclovir_4.PNG
Correct Answer: D
Rationale: A: Client A has vitiligo, a skin disorder characterized by the patchy loss of skin pigment. Vitiligo is treated with topical steroids. B: Client B has dried herpes simplex, usually treated with the antiviral medication acyclovir. C: Client C has keloids (hypertrophic scarring), which usually are not treated with medication. D: Ganciclovir (Cytovene) is an antiviral medication used in the treatment of recurrent genital herpes.
The client has been successful at controlling gastroesophageal reflux symptoms without prescription medications. Which OTC medication should the nurse explore whether the client is taking for symptom control?
- A. Aspirin once a day
- B. Famotidine
- C. Ibuprofen
- D. Desloratadine
Correct Answer: B
Rationale: A: Aspirin increases gastric acid secretion and may worsen symptoms. B: The nurse should explore whether the client is taking famotidine (Pepcid) for symptom control. Famotidine blocks histamine-2 receptors on parietal cells, thus decreasing gastric acid production. C: NSAIDs, such as ibuprofen (Motrin), do not reduce gastric acid. D: Desloratadine (Clarinex) blocks only histamine-1 receptors and is not effective against histamine-2 receptors.
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
- A. Administer O2.
- B. Turn the client on her left side.
- C. Notify the physician.
- D. No action is necessary.
Correct Answer: D
Rationale: It is an early deceleration as a result of head compression, and at this time no action is necessary. Close observation of the mother and baby is needed.
The nurse receives shift report for five clients, and all are taking lithium. Place the clients in the order of priority.
- A. The client who has a dry mouth, headache, and thirst
- B. The client who has a fever, rash, and the start of hives
- C. The client who has blurred vision, ataxia, and tinnitus
- D. The client who has mild hand tremors, nausea, and vomiting
- E. The client who has had increasing confusion, nystagmus, and just had a seizure
Correct Answer: E,C,B,D,A
Rationale: Clients with severe lithium toxicity (E), signs of toxicity (C), allergic reactions (B), side effects needing evaluation (D), and manageable side effects (A) are prioritized in that order.