Nokea
What are two major side effects of haloperidol (Haldol) the nurse should anticipate?
- A. Blood dyscrasia and extrapyramidal symptoms.
- B. Hearing loss and unsteady gait.
- C. Nystagmus and vertical gaze palsy.
- D. Alteration in level of consciousness and increased confusion.
Correct Answer: A
Rationale: major side effects of haloperidol (Haldol) include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS)
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An adult male is admitted with urolithiasis. The nurse expects which orders for this client? Select all that apply.
- A. Push fluids
- B. Strain all urine
- C. Medicate for pain PRN
- D. Clean catch daily
- E. Daily catheterizations
- F. Clear liquid diet
Correct Answer: A,B,C
Rationale: Pushing fluids promotes stone passage, straining urine captures stones for analysis, and pain medication addresses colic in urolithiasis. Clean catch, catheterization, or clear liquids are not standard.
The nurse is caring for a client who is receiving a continuous IV infusion of insulin for diabetic ketoacidosis. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 200 mg/dL.
- B. Potassium of 3.0 mEq/L.
- C. pH of 7.30.
- D. Sodium of 135 mEq/L.
Correct Answer: B
Rationale: Hypokalemia (potassium 3.0 mEq/L) is a serious complication in diabetic ketoacidosis treatment, as insulin drives potassium into cells, risking arrhythmias. Options A, C, and D are less urgent: glucose 200 mg/dL is improving, pH 7.30 is near normal, and sodium 135 mEq/L is normal.
The nurse is caring for a client with a history of bipolar disorder who is receiving valproic acid (Depakote) 500 mg PO bid. Which of the following laboratory results should the nurse report immediately?
- A. Liver enzymes elevated to twice normal.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: Elevated liver enzymes suggest hepatotoxicity, a serious valproic acid side effect. Options B, C, and D are normal.
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Creatinine 2.5 mg/dL.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A creatinine of 2.5 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.
In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?
- A. Increased 10% in height
- B. 2 deciduous teeth
- C. Tripled the birth weight
- D. Head > chest circumference
Correct Answer: C
Rationale: Tripled the birth weight. Infants typically triple their birth weight by 12 months.