Nokea
Which of the following adverse effects should the nurse include in the teaching for a client who is to begin taking tamoxifen for the treatment of breast cancer?
- A. Urinary retention
- B. Constipation
- C. Bradycardia
- D. Hot flashes
Correct Answer: D
Rationale: The correct answer is D: Hot flashes. Tamoxifen is known to cause hot flashes as a common side effect due to its estrogen-blocking properties. This is important to include in teaching as it can affect the client's quality of life. Urinary retention (A), constipation (B), and bradycardia (C) are not commonly associated with tamoxifen use. Hot flashes are a well-documented side effect, making it the most appropriate choice for client education.
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Which of the following findings is the best indication that morphine has been effective?
- A. The client's vital signs are within normal limits
- B. The client has not requested additional medication
- C. The client is sitting comfortably with eyes closed
- D. The client rates pain as 3 on a scale from 0 to 10
Correct Answer: D
Rationale: The correct answer is D because the client rating pain as 3 on a scale from 0 to 10 indicates that the morphine has effectively reduced their pain. This is a direct measure of the drug's efficacy. Choice A is not a specific indicator of pain relief. Choice B could mean the client is tolerating the pain, not necessarily that the medication is effective. Choice C is subjective and doesn't provide concrete evidence of pain relief.
A nurse administers a dose of metformin to a client instead of the prescribed dose of metoclopramidWhich of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Notify the provider.
- C. Check the client's blood glucose.
- D. Fill out an incident report.
Correct Answer: C
Rationale: The correct answer is C: Check the client's blood glucose. This is the first action the nurse should take because metformin is used to treat diabetes and can lower blood sugar levels. Checking the client's blood glucose will help assess if the client is experiencing hypoglycemia due to the medication error. Reporting the incident to the charge nurse (A) and filling out an incident report (D) are important steps, but assessing the client's immediate condition takes priority. Notifying the provider (B) can be done after ensuring the client's safety. The other options are not relevant to addressing the immediate concern of potential hypoglycemia.
Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism in a client taking haloperidol?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol, characterized by symptoms resembling Parkinson's disease. A shuffling gait, where the client takes small steps with feet barely leaving the floor, is a classic manifestation. Serpentine limb movement (A) is not typically associated with pseudoparkinsonism. Nonreactive pupils (C) can be a sign of anticholinergic toxicity, not pseudoparkinsonism. Smacking lips (D) is more indicative of tardive dyskinesia, another side effect of antipsychotics.
A nurse is caring for a client who received 0.9% sodium chloride 1 L over 4 hr instead of over 8 hr as prescribeWhich of the following information should the nurse enter as a complete documentation of the incident?
- A. IV fluid infused over 4 hr instead of the prescribed 8 hr. Client tolerated fluids well, provider notified.
- B. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
- C. 1 L of 0.9% sodium chloride completed at 0900. Client denies shortness of breath.
- D. IV fluid initiated at 0500. Lungs clear to auscultation.
- E. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. This choice clearly states the key information - the type of IV fluid, volume, and duration of infusion.
2. Mentioning that vital signs were stable indicates client's safety was monitored.
3. Notifying the provider is crucial for any deviation from the prescribed treatment plan.
Incorrect Choices:
A. Fails to mention the type of IV fluid or client's vital signs, lacks detail.
C. Although it mentions the completion time, it does not address the deviation or client's tolerance.
D. Provides irrelevant information about the initiation time and lung assessment.
E. Similar to choice B, but lacks mentioning the infusion duration which is critical for documenting the incident.
A nurse is assessing a client after administering a second dose of cefazolin IV. The nurse notes the client has anxiety, hypotension, and dyspneWhich of the following medications should the nurse administer first?
- A. Diphenhydramine
- B. Albuterol inhaler
- C. Epinephrine
- D. Prednisone
Correct Answer: C
Rationale: The correct answer is C: Epinephrine. When a client exhibits symptoms of anxiety, hypotension, and dyspnea after receiving cefazolin IV, it indicates a severe allergic reaction/anaphylaxis. Epinephrine is the first-line medication for anaphylaxis as it acts quickly to reverse the symptoms by constricting blood vessels, increasing blood pressure, and opening airways. Diphenhydramine (A) is an antihistamine that can be given as a second-line treatment. Albuterol inhaler (B) is used for bronchospasm but is not the first choice in anaphylaxis. Prednisone (D) is a corticosteroid that may be used later for inflammation but is not the initial treatment for anaphylaxis.