Exam (Verified Solutions) | Graded A
A patient is prescribed fluoxetine for major depressive disorder. What would be an important
nursing consideration when initiating this medication, especially in a young adult?
Monitor the patient for any signs of suicidal thoughts or behaviors, as SSRIs can increase the
risk of suicide in younger patients.
A 75-year-old patient with chronic hypertension is starting on lisinopril. What should the nurse
monitor closely during the first few doses?
Monitor for signs of hypotension, especially during the first dose, as ACE inhibitors like
lisinopril can cause an initial drop in blood pressure.
A patient with diabetes is prescribed metformin for glycemic control. What is the most important
nursing intervention to prevent a serious adverse effect of this medication?
Monitor renal function regularly, as metformin can cause lactic acidosis in patients with
impaired kidney function.
A patient on warfarin therapy for atrial fibrillation presents with increased bruising. What should
the nurse assess to determine if this is a result of the anticoagulant?
Assess the patient's INR (International Normalized Ratio) to ensure it is within the
therapeutic range and evaluate for signs of bleeding.
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,A patient who is receiving morphine for postoperative pain reports feeling lightheaded and dizzy.
What should the nurse do first?
Assess the patient's respiratory rate and oxygen saturation levels, as opioid medications like
morphine can cause respiratory depression.
A patient receiving rifampin for tuberculosis reports a change in the color of their urine. What
would the nurse explain to the patient about this side effect?
Inform the patient that rifampin can cause reddish-orange discoloration of urine, sweat, and
tears, which is a harmless but expected side effect.
A patient with a history of seizures is prescribed phenytoin. What is an essential nursing
intervention when administering this drug?
Monitor for signs of toxicity, such as nystagmus, ataxia, and confusion, and ensure the
patient's serum phenytoin levels are within the therapeutic range.
A patient with schizophrenia is prescribed haloperidol. What is a critical nursing consideration
regarding the potential side effects of this antipsychotic medication?
Monitor for signs of extrapyramidal symptoms (EPS) such as tremors, rigidity, and
bradykinesia, and educate the patient about the possibility of tardive dyskinesia with long-term
use.
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,A patient is receiving omeprazole for gastroesophageal reflux disease (GERD). What should the
nurse educate the patient about in terms of potential long-term side effects?
Educate the patient about the risk of vitamin B12 deficiency and bone fractures with long-
term use of proton pump inhibitors like omeprazole.
A patient on acetaminophen for pain relief presents with jaundice and confusion. What should
the nurse suspect, and what intervention is needed?
Suspect acetaminophen toxicity, particularly if the patient has exceeded the recommended
dosage. Immediate liver function tests and possibly N-acetylcysteine (NAC) administration are
required.
A patient with a history of chronic migraines is prescribed sumatriptan. What should the nurse
monitor for after administering the medication?
Monitor for signs of cardiovascular events such as chest pain or tightness, as sumatriptan can
cause vasoconstriction and increase the risk of myocardial infarction in patients with
cardiovascular disease.
A patient is started on a statin for hyperlipidemia. What is an important nursing intervention to
minimize the risk of muscle toxicity?
Monitor the patient's creatine kinase (CK) levels and assess for signs of muscle pain,
weakness, or tenderness, as statins can cause rhabdomyolysis.
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, A patient with rheumatoid arthritis is prescribed methotrexate. What should the nurse instruct the
patient to avoid while on this medication?
Instruct the patient to avoid alcohol consumption, as methotrexate can increase the risk of
liver damage, especially when combined with alcohol.
A patient with a recent myocardial infarction is prescribed atenolol. What should the nurse assess
for before administering the first dose?
Assess the patient's heart rate and blood pressure to ensure they are within a safe range, as
beta-blockers like atenolol can cause bradycardia and hypotension.
A patient who is on levothyroxine therapy for hypothyroidism is experiencing palpitations and
weight loss. What should the nurse assess in relation to these symptoms?
Assess for signs of thyroid hormone overdose, as these symptoms may indicate the dose of
levothyroxine is too high.
A patient receiving hydrocodone for pain reports increasing drowsiness and difficulty breathing.
What should the nurse do next?
Immediately assess the patient's respiratory rate and oxygen saturation levels, as opioid
medications like hydrocodone can cause respiratory depression.
A patient on lithium for bipolar disorder presents with excessive thirst and urination. What
should the nurse suspect and monitor for?
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