Rifampin can cause hepatoxicity, so elevated liver enzyme levels need to be
closely monitored and reported to the health care provider (C). Orange
discoloration of the urine is an expected side effect of this medication (A). The
potassium level (B) is normal. A BUN level of 12 mg/dL is within defined
parameters (D).
The nurse is caring for a client with heart failure who develops respiratory
distress and coughs up pink frothy sputum. Which action should the nurse take
first?
A. Draw arterial blood gases.
B. Notify the primary health care provider.
C. Position in a high Fowler's position with the legs down.
D. Obtain a chest X-ray. - ANSWER -C
Rationale:
, Positioning the patient in a high Fowler's position with dangling feet will decrease
further venous return to the left ventricle (C). The other actions should be
performed after the change in position (A, B, and D).
A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia
develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most
important?A.Administer a dose of benztropine mesylate (Cogentin) PRN.
B. Determine if the client has increased photosensitivity.
C. Provide comfort measures for sore muscles.
D. Assess the client for visual and auditory hallucinations. - ANSWER -A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
masklike face are extrapyramidal side effects associated with Thorazine. It is
most important for the nurse to administer an anticholinergic such as Cogentin to
reverse these effects (A). The others (B, C, D) may be appropriate interventions
but are not as urgent as (A).
A nurse is interviewing a mother during a well-child visit. Which finding would
alert the nurse to continue further assessment of the infant?
A. Two-month-old who is unable to roll from back to abdomen
B. Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words - ANSWER -B
Rationale:
As a developmental milestone, infants should sit unsupported by 8 months (B).
The milestone of rolling over is achieved at 5 to 6 months for most infants (A).
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