A nurse administers a dose of metformin for a client instead of the prescribed dose of
metoclopramide. Which of the following actions should the nurse take first?
A. report the incident to the charge nurse
B. notify the provider
C. check the clients blood glucose
D. fill out an incident report - ANS-C. check the clients blood glucose
THE FIRST ACTION THE NURSE SHOULD TAKE USING THE NURSING PROCESS IS TO
ASSESS THE CLIENT. THE CLIENT IS AT RISK FOR HYPOGLYCEMIA. THE NURSE
SHOULD MONITOR THE CLIENT'S GLUCOSE AND PROVIDE THE CLIENT WITH A SNACK
TO REDUCE THE RISK OF HYPOGLYCEMIA
A nurse at a clinic is providing follow - up care to a client who is taking fluoxetine for depression.
Which of the following findings should the nurse identify as an adverse effect of the medication?
A. tingling toes
B. sexual dysfunction
C. absence of dreams
D. pica - ANS-B. sexual dysfunction
SEXUAL DYSFUNCTION, INCLUDING A DECREASE LIBIDO, IMPOTENCE, AND DELAYED
ORGASM, OR ANORGASMIA, IS A COMMON ADVERSE EFFECT OF FLUOXETINE AND
OCCURS IN ABOUT 70% OF CLIENTS WHO TAKE THIS SSRI ANTIDEPRESSANT
A nurse at an urgent care clinic is collecting a history from a female client who has a UTI. The
nurse anticipates a prescription for ciprofloxacin. The nurse should identify that which of the
following client statements indicates a contraindication for administering this medication?
A. "I have tendonitis, so I haven't been able to exercise"
B. "I take a stool softener for chronic constipation"
C. "I take medication for my thyroid"
D. "I am allergic to sulfa" - ANS-A. "I have tendonitis, so I haven't been able to exercise"
THE NURSE SHOULD IDENTIFY TENDONITIS AS A CONTRAINDICATION FOR TAKING
CIPROFLOXACIN DUE TO THE RISK OF TENDON RUPTURE
A nurse is administering donepezil to a client who has Alzheimer's disease. Which of the
following findings should the nurse report to the provider immediately?
A. dyspepsia
B. diarrhea
C. dizziness
D. dyspnea - ANS-D. dyspnea
WHEN USING THE AIRWAY, BREATHING, CIRCULATION APPROACH TO CLIENT CARE,
THE NURSE SHOULD REPORT THE ADVERSE EFFECTS OF DYSPNEA, CAUSED BY
BRONCHOCONSTRICTION, TO THE PROVIDER FIRST. BRONCHOCONSTRICTION,
DYSPEPSIA, DIARRHEA, AND DIZZINESS ARE CAUSED BY THE INCREASE IN
ACETYLCHOLINE LEVEL, WHICH IS A PRIMARY EFFECT OF DONEPEZIL
, A nurse is an emergency department is caring for a client who has myasthenia gravis and is in a
cholinergic crisis. Which of the following medications should the nurse plan to administer?
A. potassium iodide
B. glucagon
C. atropine
D. protamine - ANS-C. atropine
A CHOLINERGIC CRISIS IS CAUSED BY AN EXCESS AMOUNT OF CHOLINESTERASE
INHIBITOR, SUCH AS NEOSTIGMINE. THE NURSE SHOULD PLAN TO ADMINISTER
ATROPINE, AN ANTICHOLINERGIC AGENT, TO REVERSE CHOLINERGIC TOXICITY
A nurse is an emergency department is caring for a client whose family reports the client has
taken large amounts of diazepam. Which of the following medications should the nurse
anticipate administering?
A. ondansetron
B. magnesium sulfate
C. flumazenil
D. protamine sulfate - ANS-C. flumazenil
THE NURSE SHOULD ANTICIPATE ADMINISTERING FLUMAZENIL, AN ANTIDOTE USED
TO REVERSE BENZODIAZEPINES SUCH AS DIAZEPAM
A nurse is assessing a client 1 hr after administering morphine for pain. The nurse should
identify which of the following findings as the best indication that the morphine has been
effective?
A. the client's vital signs are within normal limits
B. the client has not requested additional medication
C. the client is resting comfortably with eyes closed
D. the client rates pain as 3 on a scale from 0 to 10 - ANS-D. the client rates pain as 3 on a
scale from 0 to 10
THE CLIENT'S DESCRIPTION OF THE PAIN IS THE MOST ACCURATE ASSESSMENT OF
PAIN
A nurse is assessing a client after administering a second dose of cefazolin IV. The nurse notes
the client has anxiety, hypotension, and dyspnea. Which of the following medications should the
nurse administer first?
A. diphenhydramine
B. albuterol inhaler
C. epinephrine
D. prednisone - ANS-C. epinephrine
ACCORDING T EVIDENCE-BASED PRACTICE, THE NURSE SHOULD ADMINISTER
EPINEPHRINE FIRST TO INDUCE VASCOCONSTRICTION AND BRONCHODILATION
DURING ANAPHYLAXIS
A nurse is assessing a client who has myasthenia gravis and is taking neostigmine. Which of
the following findings should indicate to the nurse that the client is experiencing an adverse
effect?
A. tachycardia
B. oliguria
C. xerostomia
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