A nurse is assessing a client's vital signs prior to the administration of PO digoxin. The
client's BP is 144/86 mmHg, heart rate is 55/min, and the
... [Show More] respiratory rate is 20/min. The
nurse should withhold the medication and contact the provider for which of the following
findings? ----------- Correct Answer ---------- Heart Rate
Digoxin slows the conduction rate through the SA and AV nodes, thereby decreasing
the heart rate. The nurse should withhold the medication and notify the provider for a
heart rate of 55/min because this is an early indication of digoxin toxicity.
A nurse at a clinic is providing follow-up care to a client wo is taking fluoxetine for
depression. Which of the following findings should the nurse identify as an adverse
effect of the medication? ----------- Correct Answer ---------- Sexual dysfunction
Sexual dysfunction, including a decreased libido, impotence, and delayed orgasm, or
anorgasmia, is a common adverse effect of fluoxetine and occurs in about 70% of
clients who take this SSRI antidepressant.
A nurse is teaching a client about warren. The client asks if they can take aspirin while
taking the warren. Which of the following responses should the nurse make? -----------
Correct Answer ---------- Aspirin will increase the risk of bleeding
Aspirin inhibits platelet aggregation and can potentiate the action of the anticoagulant
warfarin. Therefore, the client should avoid taking aspirin because it increases the risk
for bleeding.
A nurse is assessing a client who is postoperative following an outpatient endoscopy
procedure as an indication that the client is ready for discharge? ----------- Correct
Answer ---------- The client's capnography has returned to baseline.
The nurse should identify that the client is ready for discharge when the capnography
level indicates that gas exchange is adequate.
A nurse is planning care for a client who is prescribed metoclopramide following bowel
surgery. For which of the following adverse effects should the nurse monitor? ---------
Correct Answer ---------- Sedation
Metoclopramide has multiple CNS adverse effects, including dizziness, fatigue, and
sedation.
A nurse is providing teaching to a client who has a prescription for ergotamine
sublingual to treat migraine headaches. Which of the following information should the
nurse include in her instructions? --------- Correct Answer ---------- Take one tablet at
onset of migraine
The client should take one tablet immediately after the onset of aura or headache.
A nurse is preparing to administer heparin subcutaneously to a client. Which of the
following actions should the nurse plan to take? --------- Correct Answer ----------
Administer the medication outside the 5cm (2in) radius of the umbilicus.
The nurse should administer the heparin by subcutaneous injection to the abdomen in
an area that is above the iliac crest and at least 5 cm (2 in) away from the umbili
A nurse is caring for a client who is taking acetazolamide for chronic open-angle
glaucoma. For which of the following adverse effects should the nurse instruct the client
to monitor and report? --------- Correct Answer ---------- Tingling of fingers
The nurse should instruct the client to report the adverse effect of paresthesia, a tingling
sensation in the extremities, when taking acetazolamide.
A nurse is preparing to administer medication to a client who has gout. The nurse
discovers that an error was made during the previous shift and the client received
atenolol instead of allopurinol. Which of the following actions should the nurse take first?
--------- Correct Answer ---------- Obtain the client's blood pressure.
When using the nursing process, the first action the nurse should take to prevent injury
to the client is to assess the client for adverse effects of atenolol, such as hypotension.
A nurse is preparing to administer PO sodium polystyrene sulfonate to a client client
who has hyperkalemia. Which of the following action should the nurse plan to take? -----
---- Correct Answer ---------- Monitor the client for constipation.
The nurse should monitor the client for the adverse effect of constipation and report it to
the provider because this can lead to fecal impaction.
A nurse is planning to teach about the use of a spacer to a child who has a new
prescription for a fluticasone inhaler to treat chronic asthma. the nurse should include
that the spacer deceases the risk for which of the following adverse effect of the
medication? --------- Correct Answer ---------- Oral candidiasis
Dysphonia and oral candidiasis are adverse effects of inhaled corticosteroids. Using a
spacer and rinsing the mouth after inhalation will minimize the amount of medication
remaining in the oropharynx, preventing the development of these adverse effects.
A nurse is reviewing the lab results of a client who is taking digoxin for heart failure.
Which of the following results should the nurse report to the provider? --------- Correct
Answer ---------- Potassium level 2.8 mEq/L
A potassium level of 2.8 mEq/L is below the expected reference range of 3.5 to 5
mEq/L. The nurse should notify the provider if a client has hypokalemia prior to
administration of digoxin due to the increased risk of developing digoxin toxicity and
cardiac dysrhythmias.
A nurse receives a verbal order from the provider to administer morphine five milligrams
every 4 hours subcutaneously for severe pain as needed. The nurse should identify
which of the following entries as the correct format for the medication administration
record (MAR)? --------- Correct Answer ---------- Morphine 5 mg subcut every 4 hr PRN
severe pain
The nurse should identify this entry as the correct format for the MAR. The medication
name is spelled out and there are not any abbreviations from The Joint Commission's
"Do Not Use" list included in the transcription.
A nurse is providing discharge instructions to a client who has heart failure and a new
prescription for captopril. Which of the following client statements indicates an
understanding of the teaching? --------- Correct Answer ---------- "I should take naproxen
if I develop joint pain."
Naproxen and other NSAIDs can interact with captopril, which can decrease the effect
of the antihypertensive and increase the risk of kidney dysfunction.
A nurse is caring for a client who has acute acetaminophen toxicity. The nurse should
anticipate administering which of the following medication? --------- Correct Answer ------
---- Acetylcysteine
Acetylcysteine is a specific antidote for acetaminophen toxicity. It can prevent severe
injury when given orally or by IV infusion within 8 to 10 hr.
A nurse is assessing a client 1 hours after administering morphine for pain. The nurse
should identify which of the following findings as best indication that them morphine has
been effective? --------- Correct Answer ---------- The client rates pain as 3 on a scale
from 0 to 10.
The client's description of the pain is the most accurate assessment of pain.
A nurse is providing teaching to a client who is to start treatment for asthma with
beclomethasone and albuterol inhalers. Which of the following instructions should the
nurse include in the teaching? --------- Correct Answer ---------- "Rinse your mouth after
inhaling the beclomethasone." [Show Less]