1. A nurse is caring for a client who has bipolar disorder and new prescription for lithium,
laboratory values should the nurse plan to monitor for potential adverse effect.
Ans.: Serum Sodium. The nurse should monitor the sodium level while client is taking lithium.
2. A nurse is reinforcing teaching with a client who is prescribed disulfiram to treat alcohol use
disorder. Which of the following information should the nurse include in the teaching?
Answer: Avoid using aftershave or cologne while taking this medication. The nurse should identify that
disulfiram causes a build up of acetaldehyde in the blood. Within 10 min. of consuming or touching
alcohol., the client can experience manifestation such as nausea, tachycardia, flushing, hypotension,
confusion, and weakness. The severity of the manifestation depends on the amount of alcohol present.
Therefore, the nurse should instruct the client to avoid using alcohol-based products, such as aftershave.
3. A nurse is reinforcing teaching with a client who is starting phenytoin therapy to help manage
a seizure disorder. Which of the following instructions should the nurse include?
Answer: “Brush and floss your teeth after each meal. “Phenytoin cause gingival hyperplasia, an
overgrowth of gum tissue. To minimize gum injury and discomfort the client should brush and floss after
each meal, massage her gums, take folic acid supplement, and schedule dental examination regularly.
4. A nurse is collecting data for four clients prior to administering morning medication. Which of
the following findings indicates the nurse should withhold the prescribed medication?
Answer: Apical pulse of 48/ min for a client receiving metoprolol
The heart rate is below expected range of 60 to 100/ min. Metoprolol is a selective beta blocker that will
lower the heart rate further. The nurse should withhold the medication and contact the provider for a
client who has a heart rate of less than 50 / min.
5. A nurse is preparing to administer vaccines to an adolescent during well child visit. The nurse
should check for an allergy to eggs prior to administering which of the following vaccines?
Answer: Inactivated Influenza Vaccine
6. A nurse is collecting data for a client who is scheduled to receive an initial dose of tobramycin.
Which of the following findings should the nurse report to the provider?
Answer: The clients creatine level is 2. 2 mg/dL
The creatine level is above the expected range for adult of 0.5 to 1.3 mg/dL. Indicating impaired kidney
function which increase the risk of nephrotoxicity Therefore the nurse should monitor the Creatine
clearance, BUN, and. urinalysis results to prevent kidney injury.
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, 7. A nurse is reinforcing teaching with a client who has a prescription for Rosuvastatin to treat
high cholesterol levels. For which of the following adverse effects should the nurse instruct the
client to monitor and report to the provider immediately?
ANSWER: Muscle weakness
When using urgent vs. nonurgent approach in client care, the nurse should determine that the priority
finding to report is muscle weakness because it can be manifestation of rhabdomyolysis a rare but
potentially fatal adverse effect of CoA reductase inhibitor therapy.
8. A nurse is client who has diabetes mellitus. The client received a dose of regular insulin prior to an
episode of vomiting and now is unable to eat. For which of the following manifestation should the
nurse monitor.
Answer: Confusion
A client who has hypoglycemia can become confused due to lack of glucose in the brain.
9. A nurse is reinforcing teaching with a client who has a new prescription for spironolactone. Which
of the following information should the nurse include in the teaching?
Answer: Avoid salts substitute containing potassium while taking this medication. Spironolactone is a
potassium sparing diuretics. Eating foods that contain large amount of potassium or using salt substitute
that contain potassium can increase the risk of developing HYPERKALEMIA.
10. A nurse is administering prescribed ear drops into an older adult client’s right ear. Which of
the following actions should the nurse take?
Answer: Initial drop holding the dropper 1 cm. above the ear canal.
11. A nurse is reviewing a young adult client’s medical history before administering the varicella
vaccine, for which of the following findings in the client’s medical history should the nurse withhold the
immunization and notify the provider.
Answer: Allergy to Gelatin
Having reaction to gelatin or neomycin is a contraindication for receiving varicella because it contains
both substances. The nurse should also be extremely cautious when administering the measles,
mumps, and rubella MMR vaccine to a client who is allergic to GELATIN.
12. A nurse is planning to reinforce teaching with a newly hired nurse about physiologic changes in
older adult clients that can alter pharmacokinetics. Which of the following should the nurse include as
an age- related change?
Answer: Decrease kidney function
An older adult client can experience decreased kidney function, which can lead to medication toxicity,
therefore an older adult client might require a reduced dosage of medications to decrease the risk of
adverse effect .
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