The nurse is caring for a client with breast cancer who has an order for doxorubicin IV. The nurse anticipates which common side effect of this medication?
Rationale:
C: red urine for 1-2 days after administration. Doxorubicin can cause a harmless change in urine color due to its chemical composition, often lasting for a brief period post-administration, which is a common and expected side effect.
A: permanent hair loss. While hair loss can occur, it is generally temporary with doxorubicin, differing from agents that lead to lasting alopecia.
B: halos around objects and blurred vision. These symptoms are more typical of specific medications affecting vision or conditions like glaucoma, not associated with doxorubicin treatment.
D: facial flushing and red streaking along the vein. Such reactions are indicative of infusion-related reactions, not a typical side effect of doxorubicin, which primarily affects urine color instead.
The ED nurse admits a client with second-degree burns to the arms and third-degree burns to the legs. Based on the Parkland formula, which IV fluid would the nurse anticipate for this client during the first 24 hours?
Rationale:
Crystalloid solutions. The Parkland formula recommends crystalloid solutions for fluid resuscitation in burn patients, as they effectively expand intravascular volume and maintain hydration, crucial for recovery during the initial 24 hours post-injury.
A: D5W This option lacks the necessary electrolyte balance required for burn treatment, which is critical for effective fluid resuscitation in such severe cases.
B: Colloid solutions While colloids can be beneficial in certain situations, they are not the first-line choice for initial fluid resuscitation in burn patients, making them less suitable here.
D: 5% albumin in isotonic saline This option is inappropriate as it is not typically used in the initial resuscitation phase for burns, where crystalloids are preferred for optimal fluid replacement.
A client is ordered to receive 1,000 ml of D5W over 6 hours. The infusion set administers 10 gtt/mL. At what rate (gtt/min) should the nurse set the flow?
Rationale:
To achieve the required infusion of 1,000 ml of D5W over 6 hours, the flow rate should be set at 28 gtt/min.
Calculating the flow rate involves determining the total volume and time, converting hours to minutes, and applying the drop factor. The resulting rate aligns perfectly with the necessary administration for optimal patient care.
A: 24 gtt/min This rate underestimates the necessary flow, resulting in insufficient volume delivered within the required timeframe, potentially compromising the treatment and hydration goals.
B: 26 gtt/min While closer, this flow rate still falls short of the calculated requirement, leading to an incomplete infusion that could affect the patient's recovery and hydration status.
D: 30 gtt/min This flow rate exceeds the needed delivery, risking fluid overload and possible complications, while also failing to adhere to the precise calculations for the prescribed infusion.
The nurse is teaching a client about alendronate sodium (Fosamax). Which statement by the client indicates a need for further teaching?
Rationale:
I should take this with a meal. Taking alendronate sodium on an empty stomach enhances its absorption, while food can significantly interfere with its effectiveness. Clients must understand the importance of proper administration to ensure optimal treatment outcomes.
B: I will call my doctor if I develop a fever. Monitoring for fever is essential, as it may indicate an adverse reaction or infection requiring medical attention.
C: I should not lie down for at least 30 minutes. This statement aligns with the guidelines for alendronate, preventing esophageal irritation and ensuring proper medication absorption.
D: Dairy products reduce the absorption of this medicine. This statement accurately reflects the interaction between dairy and alendronate, emphasizing the need to avoid dairy at the time of medication intake.
The nurse is preparing to administer 12.4 mL of liquid medication via oral syringe. Which of the following actions by the nurse indicate an understanding of how to give oral medications via syringe?
Rationale:
The nurse demonstrates an understanding of administering oral medications via syringe by ensuring that the entire dose is accurately measured and administered without using inappropriate methods or tools.
A: The nurse uses either an oral or parenteral syringe to administer the medication. Mixing syringes can compromise dosage accuracy, leading to potential medication errors and affecting patient safety.
B: The nurse pours 10 mL of the medication into a 30 mL medicine cup, then adds 2.4 mL with a 3 mL syringe. This method lacks precision in measuring the total required dosage of 12.4 mL.
C: The nurse pours 10 mL of the medication into a 30 mL medicine cup, then adds 2.4 mL with a 5 mL syringe. This approach can lead to inaccuracies in the final dose administered, risking patient safety.
D: The nurse pours 10 mL of the medication into a 30 mL medicine cup, then slowly adds the remainder until it is almost halfway between the 10 mL mark and 15 mL mark. This imprecise measuring method compromises the accuracy of the medication dosage.
The nurse is caring for a client with a staph infection. The client has orders for vancomycin 15 mg/kg per 12 hours. The client weighs 136 pounds. How much of this medication will the client receive every 12 hours?
Rationale:
930 mg
To calculate the medication dosage, first convert the client's weight from pounds to kilograms (136 lbs ÷ 2.2 = 61.82 kg). Then, multiply the weight in kg by the prescribed dosage (15 mg/kg), resulting in 927.3 mg, which rounds to 930 mg every 12 hours.
A: 720 mg 720 mg does not correspond to the calculated dosage based on the client's weight and the prescribed rate, showing a significant underestimation of the required medication.
B: 1,080 mg 1,080 mg exceeds the calculated dosage, indicating a misunderstanding of the weight-based calculation necessary to determine the appropriate amount of vancomycin for the client.
C: 750 mg 750 mg falls short of the accurate calculation, reflecting a miscalculation in the weight-to-dose conversion required for administering the correct amount of medication.
The nurse is caring for a client who presents with increased ammonia levels, elevated BUN, and altered mental status. Which medication would the nurse anticipate the health care provider ordering for this client?
Rationale:
Lactulose is the medication the nurse would anticipate being ordered for the client. It acts as a laxative that helps reduce ammonia levels by promoting its excretion through the intestines, thus improving mental status.
B: Sucralfate primarily protects the gastrointestinal lining and does not address elevated ammonia levels or altered mental status, failing to target the underlying cause of the client’s condition.
C: Lamotrigine is an anticonvulsant used for mood stabilization and seizure control, not indicated for managing ammonia levels or addressing hepatic encephalopathy in this clinical scenario.
D: Gabapentin, while effective for neuropathic pain and seizures, does not influence ammonia levels or mental status changes, making it irrelevant to the treatment of hepatic-related complications.
The nurse is caring for a client who has an order for ceftriaxone IV. The client is awake and alert and has been taking PO medications and eating. The IV ceftriaxone is not available in the automatic medication dispenser. What should the nurse do next?
Rationale:
Call the pharmacy to send up the missing IV medication. This action ensures the client receives the prescribed ceftriaxone IV, which is essential for their treatment and cannot be substituted with oral medication in this instance.
A: hold the medication since the client is afebrile. The client's afebrile state does not negate the need for the prescribed IV ceftriaxone, as it is crucial for effective treatment.
C: obtain the PO ceftriaxone from the medication dispenser and administer it. Administering oral ceftriaxone instead of IV fails to meet the specific treatment requirements, as the IV form is necessary.
D: call the health care provider and see if the client can be switched over to oral ceftriaxone. Switching to oral ceftriaxone is inappropriate without a thorough assessment of the client's need for IV administration.
The mental health unit nurse is precepting a student nurse. Together they are caring for a client with schizophrenia. The nurse asks the student nurse to select the atypical antipsychotic from the client's medication list. The nurse anticipates the student nurse to select which medication?
Rationale:
C: risperidone. Risperidone is classified as an atypical antipsychotic, effective in treating symptoms of schizophrenia by targeting both positive and negative symptoms, thus improving overall patient outcomes in mental health care.
A: loxapine. Loxapine, while used for schizophrenia treatment, falls under typical antipsychotics, which primarily address positive symptoms, lacking the broader efficacy associated with atypical medications like risperidone.
B: thioridazine. Thioridazine belongs to the category of typical antipsychotics, primarily effective for positive symptoms of schizophrenia, limiting its use in comprehensive treatment plans compared to atypical alternatives.
D: haloperidol. Haloperidol is a typical antipsychotic, focusing mainly on positive symptoms of schizophrenia. Its side effect profile is often less favorable compared to atypical antipsychotics like risperidone.
The charge nurse is working with a student nurse who reports that her assigned client has severe flushing of the upper body following an IV antibiotic infusion. The charge nurse understands that the antibiotic likely responsible for this 'red man syndrome' is which medication?
Rationale:
D: Vancomycin is known to cause 'red man syndrome,' characterized by severe flushing, particularly when infused too quickly. This reaction occurs due to histamine release, which is specific to vancomycin administration.
A: Cephalexin does not typically induce 'red man syndrome,' as it has a different mechanism of action and side effects, mainly involving hypersensitivity reactions rather than histamine release.
B: Amoxicillin is not associated with 'red man syndrome' symptoms; rather, it may cause other allergic reactions, but these do not include the flushing characteristic of this specific syndrome.
C: Gentamicin does not cause 'red man syndrome.' Its side effects are primarily related to nephrotoxicity and ototoxicity, lacking the flushing response associated with vancomycin infusions.
The nurse is caring for a client diagnosed with tuberculosis. The physician plans to treat the client with a first-line medication. Which medication should the nurse prepare to administer?
Rationale:
Rifampin is the medication the nurse should prepare to administer. This first-line drug is essential for treating tuberculosis due to its effectiveness in eradicating Mycobacterium tuberculosis and preventing resistance.
B: Ciprofloxacin This medication is primarily used for bacterial infections but is not a first-line treatment for tuberculosis, making it unsuitable for this specific diagnosis.
C: Levofloxacin Although levofloxacin is an antibiotic, it is considered a second-line treatment for tuberculosis and not the preferred choice in managing this infection.
D: Streptomycin While streptomycin can be used for tuberculosis, it is classified as a second-line drug, making it less optimal than rifampin for initial treatment.
The nurse has an order to administer enoxaparin (Lovenox) 40 mg subcutaneously. When the automatic medication dispenser opens, however, the nurse finds enoxaparin 80 mg in the pocket. Which is the correct action by the nurse?
Rationale:
Notify the pharmacy to correct the error.
The nurse must ensure patient safety and medication accuracy. Reporting the discrepancy to the pharmacy allows for proper rectification of the medication error, preventing potential overdose and ensuring compliance with established protocols for medication administration.
B: skip the morning dose of the medication. Omitting the dose could lead to insufficient anticoagulation, putting the patient at risk for thromboembolic events, which is not an appropriate solution.
C: call the health care provider for order clarification. While seeking clarification is important, the immediate action should involve notifying the pharmacy to rectify the medication error before considering further steps.
D: waste half of the enoxaparin and give the remaining 40 mg. Administering a partial dose is not advisable without proper authorization or adjustment of the order, as it contravenes safe medication practices.
A client with suspected vitamin C toxicity presents to the ED. Which manifestations of toxicity would the nurse expect in this client? Select all that apply.
Rationale:
Occult rectal bleeding is a manifestation of vitamin C toxicity. Excessive ascorbic acid can lead to gastrointestinal disturbances, including irritation and bleeding, which aligns with the client's presentation in the ED.
A: Muscle weakness does not correlate with vitamin C toxicity and is typically associated with other deficiencies or conditions, rather than excess vitamin C intake affecting muscle function.
B: Halos around objects are indicative of visual disturbances often linked to conditions like glaucoma, not a symptom of vitamin C toxicity, which primarily affects gastrointestinal health.
D: Dry mucous membranes are not characteristic of vitamin C toxicity; rather, they may indicate dehydration or other unrelated issues, as vitamin C generally aids in hydration and tissue health.
E: Increased estrogen levels are unrelated to vitamin C toxicity, as this vitamin does not influence hormonal regulation directly, and its excess is not known to cause hormonal imbalances.
A 12-year-old client has new orders for amphetamine and dextroamphetamine (Adderall) for attention-deficit/hyperactivity disorder. The nurse should alert the client's caregivers about which adverse effect?
Rationale:
B: Seizures
Amphetamines, such as Adderall, can potentially lead to seizures, especially in pediatric patients. This risk necessitates that caregivers be informed, allowing for vigilant monitoring of the child's response to the medication.
A: Nausea
While nausea may occur as a side effect of amphetamines, it is typically less severe and not as critical to monitor compared to the potential for seizures.
C: Weight gain
Amphetamines are more commonly associated with weight loss due to appetite suppression, making weight gain an unlikely concern and not a significant adverse effect for caregivers to monitor.
D: Constipation
Constipation can occur but is generally not a prominent adverse effect of amphetamines. It is less severe and less concerning compared to the risk of seizures in this context.
The nurse is caring for a client with AIDS who is diagnosed with thrush. Which instruction should the nurse give to the client's caretaker, who will be administering nystatin (Mycostatin) oral solution?
Rationale:
Administer the medication after meals. This timing enhances the effectiveness of nystatin, as food helps provide a protective barrier and may improve absorption, ensuring optimal antifungal action against the thrush.
A: take the medication before meals. Taking nystatin before meals may lead to reduced effectiveness, as an empty stomach could hinder the medication's contact with the affected oral mucosa.
C: mix the medication with orange juice. Mixing nystatin with orange juice alters its pH and can potentially reduce its antifungal efficacy, compromising the treatment for thrush.
D: take the medication at bedtime. Administering nystatin at bedtime may not allow for sufficient contact time with the thrush lesions, limiting the medication's effectiveness during crucial hours of oral activity.
The ED nurse has admitted a client with suspected overdose of tricyclic antidepressants. Which signs and symptoms does the nurse expect to find in this client? Select all that apply.
Rationale:
Confusion, dry mouth, and dysrhythmias are expected signs and symptoms of a tricyclic antidepressant overdose due to their anticholinergic effects, which can significantly impact the central nervous system and cardiac function.
C: bradycardia Bradycardia typically does not occur with tricyclic antidepressant overdose; instead, tachycardia is more common due to the drug's anticholinergic properties affecting heart rate.
E: constricted pupils Tricyclic antidepressants usually cause dilated pupils, not constricted ones, as they inhibit the action of acetylcholine, leading to mydriasis rather than miosis.
F: flushing of the skin Flushing is not characteristic of tricyclic antidepressant overdose; patients often exhibit pallor or dry skin due to the anticholinergic effects rather than increased vasodilation.
The nurse is working in the mental health unit and is educating a group of student nurses about atypical antipsychotics. Which statement by one of the student nurses requires further teaching about this class of drugs?
Rationale:
A: These drugs can cause bradycardia.
Atypical antipsychotics are primarily associated with metabolic side effects rather than bradycardia, which is more commonly linked to other medication classes. The statement misrepresents the typical cardiovascular effects of these drugs, necessitating further education.
B: This class of drugs can cause diabetes.
Atypical antipsychotics are known for increasing the risk of metabolic syndrome, including diabetes, making this statement accurate and relevant to their side effect profile.
C: Weight gain and obesity are side effects of these drugs.
Atypical antipsychotics frequently contribute to significant weight gain and obesity, reflecting a well-documented concern among healthcare professionals related to their long-term use and patient management.
D: Rarely, neuroleptic malignant syndrome can occur and may be fatal.
Neuroleptic malignant syndrome is a serious but infrequent reaction to antipsychotic medications, making this statement valid and important for understanding potential complications associated with their use.
The nurse is caring for a client who is taking bethanechol chloride (Urecholine) for neurogenic bladder. Which of the following does the nurse understand is correct concerning this medication?
Rationale:
Atropine sulfate should be readily available when a client receives this medication. Bethanechol chloride can cause bradycardia and other parasympathetic effects, making atropine an essential antidote for managing potential adverse reactions during treatment.
A: This is the primary treatment for clients with a urinary obstruction. Bethanechol chloride primarily treats neurogenic bladder, not mechanical obstructions, which require different management strategies.
B: If the client cannot swallow pills, the medication may be given by the IV or IM route. Bethanechol chloride is only administered orally, as its formulation does not support parenteral routes safely or effectively.
C: Urecholine should be given with food to prevent nausea and vomiting. While food may help with tolerance, this medication is not specifically indicated for administration with meals to mitigate gastrointestinal effects.
The nurse is caring for a client receiving total parenteral nutrition (TPN). During the assessment, the nurse notes absence of breath sounds on the right side, where the central catheter is placed. Which of the following does the nurse suspect is responsible for this abnormal assessment finding?
Rationale:
Absence of breath sounds on the right side suggests pneumothorax. This condition can occur if the central catheter inadvertently punctures the pleura, leading to air accumulation in the pleural cavity, which impedes normal lung function.
A: air embolism A sudden obstruction in the vascular system caused by air bubbles would present with different symptoms, such as chest pain and respiratory distress, not specifically absent breath sounds.
B: fluid overload This condition typically manifests with signs like edema and respiratory distress due to fluid retention, which would not directly cause absence of breath sounds in one lung area.
D: refeeding syndrome This metabolic complication arises from nutritional replenishment and presents with electrolyte imbalances. It does not result in localized respiratory findings such as absent breath sounds on one side.
The nurse is providing discharge teaching to a client who has been prescribed prednisone. The nurse instructs the client to report which symptom to the health care provider?
Rationale:
Anxiety or confusion should be reported to the health care provider as potential side effects of prednisone, indicating possible adverse reactions affecting the client’s mental health and requiring attention.
A: Increased appetite This symptom is a common side effect of prednisone and generally not alarming, thus does not necessitate immediate reporting to a health care provider.
C: Strong, bounding pulses While this can indicate fluid retention, it is not as critical as anxiety or confusion, which may signify a more severe impact on mental health.
D: Weight gain of 3 pounds A slight weight gain can occur with prednisone use and is typically considered a normal result of the medication, not a signal for urgent reporting.