Correct Solutions 2024
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? - Answer -Respiratory 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? -
Answer -Sore 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? - Answer -
Restrict 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? - Answer -Muscle 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? - Answer -Dispose 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? - Answer -"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? - Answer -
Hyporeflexia
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? - Answer -"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? - Answer -Vertigo
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? - Answer -"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? - Answer -Trimethoprim/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? - Answer -Hyperkalemia
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? - Answer -Press 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? - Answer -"Your daughter will receive three doses of this immunization over 6 months."
Clients should receive three doses of HPV2 over a 6-month period.