Nokea
A nurse is administering naloxone to a client who has developed an adverse reaction to morphine. The nurse should identify which of the following findings as a therapeutic effect of naloxone?
- A. Decreased nausea
- B. Increased pain relief
- C. Decreased blood pressure
- D. Increased respiratory rate
Correct Answer: D
Rationale: The correct answer is D: Increased respiratory rate. Naloxone is an opioid antagonist that works by blocking the effects of opioids, such as morphine. By administering naloxone to the client experiencing an adverse reaction to morphine, the nurse can reverse the respiratory depression caused by the morphine. This reversal leads to an increase in the client's respiratory rate, which is a therapeutic effect of naloxone in this situation.
Incorrect choices:
A: Decreased nausea - Naloxone does not directly address nausea.
B: Increased pain relief - Naloxone does not provide pain relief but reverses the effects of opioids.
C: Decreased blood pressure - Naloxone may lead to an increase in blood pressure due to its effects on reversing opioid-induced respiratory depression.
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A nurse is caring for a client who is taking lithium and reports starting a new exercise program. The nurse should assess the client for which of the following electrolyte imbalances?
- A. Hypocalcemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypomagnesemia
Correct Answer: C
Rationale: The correct answer is C: Hyponatremia. When a client taking lithium starts a new exercise program, they may sweat more, leading to sodium loss. Hyponatremia is characterized by low sodium levels in the blood, which can be exacerbated by the diuretic effect of lithium. This can result in symptoms such as confusion, muscle cramps, weakness, and seizures. Assessing for hyponatremia is crucial to prevent complications.
Incorrect choices:
A: Hypocalcemia - Not directly related to lithium or exercise.
B: Hypokalemia - More commonly associated with diuretic use or excessive potassium loss.
D: Hypomagnesemia - More commonly seen in alcoholism or malnutrition.
A nurse is preparing to administer subcutaneous heparin to a client. Which of the following should the nurse take?
- A. Massage the site after administering the medication
- B. Use a 21-gauge needle for the injection
- C. Aspirate before injecting the medication
- D. Insert the needle at least 5 cm (2 in) from the umbilicus
Correct Answer: D
Rationale: The correct answer is D: Insert the needle at least 5 cm (2 in) from the umbilicus. This is crucial to prevent any potential harm to the abdominal organs located around the umbilicus. Inserting the needle too close could lead to injury or bleeding. Massaging the site after administering (A) is not recommended as it can cause bruising or discomfort. Using a 21-gauge needle (B) is not specified for subcutaneous heparin injections. Aspirating before injecting (C) is not necessary for subcutaneous injections, as the risk of hitting a blood vessel is low.
A nurse is assessing a client who reports taking over-the-counter antacids. Which of the following findings should the nurse identify as a manifestation of hypercalcemia?
- A. Constipation
- B. Decreased urine output
- C. Positive Trousseau's sign
- D. Headache
Correct Answer: A
Rationale: The correct answer is A: Constipation. Hypercalcemia can result from excessive intake of antacids containing calcium carbonate. High levels of calcium in the blood can lead to constipation due to its inhibitory effect on smooth muscle contraction in the intestinal tract. Decreased urine output (choice B) is more indicative of dehydration or renal issues. Positive Trousseau's sign (choice C) is associated with hypocalcemia, not hypercalcemia. Headache (choice D) is a nonspecific symptom and not a typical manifestation of hypercalcemia.
A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following should the nurse identify as an adverse effect of this medication?
- A. Hypoglycemia
- B. Bradycardia
- C. Red man syndrome
- D. Hypotension
Correct Answer: D
Rationale: The correct answer is D: Hypotension. Phenytoin can cause hypotension as an adverse effect due to its vasodilatory properties. The drug can cause a decrease in blood pressure, leading to symptoms such as dizziness and lightheadedness. This adverse effect is important for the nurse to recognize as it can potentially lead to complications such as falls in the client.
A: Hypoglycemia is not a common adverse effect of phenytoin.
B: Bradycardia is not a typical adverse effect of phenytoin.
C: Red man syndrome is associated with vancomycin, not phenytoin.
Summary: Phenytoin is more likely to cause hypotension as an adverse effect, rather than hypoglycemia, bradycardia, or red man syndrome.
A nurse is providing teaching to a client about the administration of omeprazole. Which of the following should the nurse include?
- A. You cannot take this medication with an antacid.
- B. You should reduce your intake of calcium while taking this medication.
- C. You should take this medication before meals.
- D. You can take a second dose if symptoms persist up to 2 hours after the first dose.
Correct Answer: C
Rationale: Rationale: Choice C is correct because omeprazole is a proton pump inhibitor that works best when taken before meals to inhibit gastric acid secretion. This timing ensures optimal effectiveness of the medication. Choices A, B, and D are incorrect. Choice A is inaccurate because omeprazole can be taken with antacids, but it is recommended to be taken separately. Choice B is incorrect as there is no specific need to reduce calcium intake while taking omeprazole. Choice D is incorrect as taking a second dose without medical advice may lead to overdosing and adverse effects.