Nokea
A client receiving amphotericin B (Fungizone) 1 mg in 250 cc of 5% dextrose in water IV over a 2-hour period.
The nurse should be MOST concerned if which of the following was observed?
- A. BUN 7.2 mg/dL, creatinine 0.5 mg/dL.
- B. BP 90/60, complaints of fever and chills.
- C. Complaints of burning on urination, thirst, and dizziness.
- D. AST (SGOT) 12 U/L, ALT (SGPT) 14 U/L, total bilirubin 0.2 mg/dL.
Correct Answer: B
Rationale: Strategy: 'MOST concerned' indicates an untoward effect of the medication. (1) normal results, causes renal toxicity, BUN and creatine would be elevated, normal BUN 7-18 mg/dL, normal creatine 0.6-1.2 mg/dL (2) correct-monitor vital signs every 30 min (3) not side effect of medication (4) normal AST (formerly SGOT) 8-20 U/L, normal ALT (formerly SGPT) 8-20 U/L, normal bilirubin 0.1-1.0 mg/dL, may cause elevation, check liver function studies weekly, notify physician if elevated
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An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the allergies listed below. Which of these allergies should all health care personnel be aware of?
- A. Shellfish
- B. Molds
- C. Balloons
- D. Perfumed soap
Correct Answer: C
Rationale: Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves.
Which finding indicates a need for further assessment of the client scheduled for a magnetic resonance imaging?
- A. The client is an insulin-dependent diabetic.
- B. The client refuses a corner bed.
- C. The client is allergic to shellfish.
- D. The client has a history of asthma.
Correct Answer: C
Rationale: Shellfish allergy may indicate iodine sensitivity, relevant for MRI contrast dye, requiring further assessment. Diabetes , bed preference , and asthma are not contraindications.
A client before administration of captopril (Capoten).
The MOST appropriate nursing action before administration of captopril (Capoten) would be to check the client's
- A. apical pulse for 60 seconds.
- B. blood pressure.
- C. urine output.
- D. temperature.
Correct Answer: B
Rationale: Strategy: Think about each answer choice and how it relates to Capoten. (1) important, but not a priority (2) correct-is an antihypertensive that necessitates that a BP be assessed prior to administration (3) important, but not priority (4) unnecessary to assess prior to the administration of the medication
The nurse is teaching a client with a new diagnosis of osteoporosis about alendronate (Fosamax). Which of the following instructions should the nurse include?
- A. Take the medication with milk.
- B. Remain upright for 30 minutes after taking.
- C. Stop the medication if bone density improves.
- D. Avoid regular bone density Test s.
Correct Answer: B
Rationale: Remaining upright for 30 minutes prevents esophageal irritation from alendronate. Options A, C, and D are incorrect.
The nurse notes dark red blood and a few clots in the catheter of a client two days after a transurethral prostatectomy (TURP). The nurse should first:
- A. Prepare the client for a return to surgery.
- B. Apply traction to the urethral catheter.
- C. Document the findings as normal.
- D. Decrease the client's oral fluid intake.
Correct Answer: B
Rationale: The appearance of dark red blood with a few clots indicates a venous bleed. Traction to the urethral catheter and increasing the client's fluid intake should be tried first before calling the doctor. Answer A would be indicated for the client with an arterial bleed, which is characterized by the appearance of bright red blood and many clots in the catheter, so it is incorrect.