A nurse is monitoring a client who has just returned to the unit following surgery. The client
received an initial dose of morphine 5 mg IV bolus for pain relief. Which of the following
adverse effects should the nurse report immediately to the provider? - ANSRespiratory rate
11/min
When using the airway, breathing, circulation approach to client care, the priority finding is a
respiratory rate of 11/min indicating respiratory depression.
A nurse is reinforcing teaching with a client who is prescribed captopril for hypertension.
Which of the following side effects should the nurse instruct the client to report to the
provider immediately? - ANSSore throat
The greatest risk to the client is infection related to neutropenia. Unexplained fever, sore
throat, and fatigue can indicate an infection and should be immediately reported to the
provider.
A nurse is reinforcing teaching with a client who has a new prescription for spironolactone for
hypertension. Which of the following instructions should the nurse include in the teaching? -
ANSRestrict foods high in potassium.
Spironolactone is a potassium-sparing diuretic, which can cause hyperkalemia. Therefore,
the client should restrict foods that are high in potassium.
A nurse is reinforcing teaching with a client about the adverse effects of simvastatin. For
which of the following adverse effects should the nurse instruct the client to monitor? -
ANSMuscle pain
The nurse should instruct the client to notify the provider if muscle pain or tenderness
develops, because this could indicate rhabdomyolysis.
A nurse is performing the third check before administering hydromorphone to a client. After
opening the unit-dose packet, the client tells the nurse he does not want to take the
medication now. Which of the following actions should the nurse take? - ANSDispose of the
medication with a second nurse as a witness.
The nurse must have a witness when disposing of a controlled substance.
A nurse is caring for a client who is prescribed an IM injection of penicillin G benzathine. The
client asks why the injection must be given IM instead of through his IV line. Which of the
following is the correct response by the nurse? - ANS"Your medication can't be given IV
because it is not water-soluble."
Medications cannot be administered IV if they are not water-soluble.
A nurse is assisting with the care of a client who is in preterm labor and is receiving
magnesium sulfate by continuous IV infusion. Which of the following findings indicats
magnesium toxicity? - ANSHyporeflexia
Magnesium sulfate depresses neuromuscular activity, leading to muscle weakness and
paralysis. Therefore, hyporeflexia can indicate magnesium toxicity.
, A nurse is reinforcing teaching with a client who is prescribed a scopolamine patch for
motion sickness. Which of the following client statements indicates an understanding of the
teaching? - ANS"I should place the patch behind my ear."
The client should place the scopolamine patch behind the ear.
A nurse is monitoring a client who is receiving IV amphotericin B. Which of the following
findings indicates an adverse reaction to this medication? - ANSVertigo
Ototoxicity is an adverse effect of amphotericin B. Manifestations of ototoxicity include
vertigo, tinnitus, and hearing loss.
A nurse is reinforcing teaching with a client who is using phenylephrine nasal spray three
times daily and reports rebound congestion. Which of the following instructions should the
nurse include to reduce the effects of rebound congestion? - ANS"Discontinue use in the left
nostril, then in the right nostril."
Discontinuing the drug one nostril at a time can overcome rebound congestion.
A nurse is caring for a client who has just received a prescription for tolbutamide to treat
diabetes mellitus. The nurse should question the prescription if the client reports which of the
following medication allergies? - ANSTrimethoprim/sulfamethoxazole
Clients who have a hypersensitivity to sulfonamide antibiotics might also be allergic to
sulfonylureas such as tolbutamide. Therefore, the nurse should question the client's
prescription for tolbutamide.
A nurse is caring for a client who has a new prescription for eplerenone to treat
hypertension. For which of the following adverse effects should the nurse monitor? -
ANSHyperkalemia
The client is at risk for increased potassium levels because eplerenone can cause potassium
retention.
A nurse is instilling timolol eyedrops for a client who has glaucoma. Which of the following
actions is appropriate for the nurse to take after instilling the eyedrops? - ANSPress the
nasolacrimal duct.
This action will prevent the medication from absorbing into systemic circulation.
A nurse is reinforcing teaching with the parent of a 14-year-old client regarding
administration of bivalent human papillomavirus vaccine (HPV2). Which of the following
should the nurse include in the teaching? - ANS"Your daughter will receive three doses of
this immunization over 6 months."
Clients should receive three doses of HPV2 over a 6-month period.
A nurse is reinforcing teaching with a client who has a new prescription for a
beclomethasone inhaler. Which of the following client statements indicates an understanding
of the teaching? - ANS"I will hold my breath for 5 seconds after administering the
medication."
The nurse should instruct the client to hold his breath for 5 to 10 seconds after administering
the medication and then exhale slowly. This allows the medication to be absorbed in the
client's lungs.