1. A nurse is caring for a client who is taking phenytoin, for which of the following adverse effects
should the nurse monitor and report to the provider
... [Show More]
a. Cognitive impairment
b. Tachycardia
c. Elevated blood pressure (HYPOTENSION and DYSRHYTHMIAS)
d. Tinnitus
Phenytoin (Dilantin) - Anticonvulsant. monitor for any manifestations of CNS effects (such as cognitive impairment), notify the provider if they occur. (p. 96 ATI PHARM)
2. MISSING 3 MISSING
4. A nurse is teaching a client who has a history of acute myocardial infarction about taking metoprolol
to treat angina. Which of the following instructions should the nurse include? Page 158
a. Stop taking the medication if you become dizzy (NEVER discontinue abruptly)
b. Check your pulse rate daily (Bradycardia, withhold if pulse under 50)
c. Expect to see an increase in your urinary output
d. Call you provider if you lose more than 1 pound per week (complication of decreased CO - weight gain
- call provider)
metropolol (Lopressor) - Beta Blockers. Beta1 - affects only the heart. Decreases HR - decreases myocardial contractility
5. A nurse is caring for a client who develops an anaphylactic reaction to IV antibiotic administration. After assessing the client’s respiratory status and stopping the medication infusion, which of the following actions should the nurse take next?
though) B.
treatment) C. Replace the solution with with 0.9 % sodium chloride
D. Give diphenhydramine IM
Rationale: If manifestations occur, stop transfusion (ATI’s specific to BLOOD TRANSFUSION, but wouldn’t you still give epi?), notify provider, and then keep IV line open with NS (in this case, replace the bag with NS?) Then, Have epi ready for IM or IV injection. Or do you elevate the legs? LOL
6. A nurse is assessing a client who is receiving OXYTOCIN via continuous IV infusion for labor augmentation. The nurse notes six contractions in a 10 minute period with a nonreassuring FHR. Which of the following actions should the nurse take first?
a. Administer Terbutaline 0.25 mg subcutaneously
b. Discontinue the oxycontin IV infusion (INC flow to fetus, control contractions, but not priority)
c. Turn
the client on the left side (greatest risk is injury from uteroplacental insufficiency, priority!)
d. Apply oxygen at 10 L / min via face mask
Rationale: Idk. I hate maternity. Someone else rationalize this shit.
Looking through Padgham’s OB notes, reposition goes first apparently. And then I have a note on the bottom, per TB, O2 first.
7. A nurse is administer lactated ringer's solution at 100ml/hr. The drop factor of the manual IV tubing is 15 gtt/ml. The nurse should set the manual IV infusion to deliver how many drops per minute? Round the answer to the nearest whole number? mL / min x gtts 100 x 15/60 = 25 gtt/min
8. A client who has active Tuberculosis and is taking rifampin reports that this urine and sweat have developed a red orange tinge. Which of the following actions should the nurse take ? page 376
a. Prepare the client for dialysis
b. Instruct the client to increase the fluid intake
c. Check the the clients liver function tests results
d. Document this as an expected finding
Broad Spectrum Antimycobacterial (antituberculosis) - inform clients of expected orange color of urine, sweat, saliva, and tears.
9. A nurse is teaching a client about self administration of enoxaparin. Which of the following instructions should the nurse include? (Select all that apply)
a. Grasp the skin between the thumb and forefinger, while injecting the medication - i don’t think “grasping” and “pinching” is the same thing. But idk. Actually wait….maybe on this sentence they are b.
Alternate the injection sites between the side of the abdomen - rotate and record injection sites c.
Expel the air bubble from the prefilled syringe
- do not expel the air from prefilled syringe unless adjustments must be made with the dose
d. Massage the insertion site after injecting the medication - do not rub the injection site for 1-2 min after injection
e. Insert the entire length of the needle into the skin during injection - insert needle completely enoxoparin (Lovenox) - anticoagulant
10. A nurse is caring for a client who is receiving warfarin to treat atrial fibrillation. Which of the following laboratory lab values should the nurse identify as the outside the expected range for this client?
A. aPTT 36 seconds 35 - 45 seconds
B.Hgb 15.2 g/dl ( 12- 16)
C.Hct 43 % (35- 45)
D. INR 4.5 (2-3 seconds)
PT/INR - for Warfarin; PTT/aPTT - for Heparin
11. A nurse is caring for a client who is receiving ondansetron IV. Which of the following is an indication that the ondansetron is effective?
a. Increased urinary output
b. Decreased Nausea Antiemetic
c. Absence of peripheral neuropathy
d. Reduced dizziness
Ondansetron - antiemetic: prevents emesis by blocking serotonin receptors; PO, IM, or IV [Show Less]