A nurse is administering methotrexate to a client who has lymphosarcoma. The nurse should
encourage the client to maintain an adequate fluid intake to prevent which of the following
adverse effects of the medication
A. Kidney damage
B. Alopecia
C. Thrombocytopenia
D. Dermatitis - ANS-A
The pt needs 2,000-3,000 mL of fluids per day to promote medication excretion and prevent
kidney damage
A nurse is assessing a client for pain who is 4 hr postoperative following surgery and still
experiencing the effects of anesthesia. Which of the following findings should the nurse identify
as an indication that the client might be experiencing pain and requires pain medication
A. Reduced blood glucose
B. Pupil constriction
C. Diaphoresis
D. Facial flushing - ANS-C
A client in pain can be come diaphroetic in an attempt to keep the body temperature under
control during stress
--
A, blood glucose can increase in a client who has pain as the body attempts to make more
energy available
B, pupils can dilate in a client who has pain to help improve vision
D, a client in pain can become pale as the body shifts blood to the central circulation and away
from the peripheral circulation
A nurse is assessing a client who has Alzheimer's disease and is taking oral rivastigmine. Which
of the following findings indicates the client is experiencing an adverse effect of the medication
A. Diarrhea
B. Tachycardia
C. Dry skin
D. Weight gain - ANS-A
Diarrhea is an adverse effect of this med d/t the peripheral cholinergic effect of the med
--
,B, the med is a cholinesterase inhibitor, which causes cholinergic actions such as bradycardia,
AV block, and cardiac arrest
C,the med is a cholinesterase inhibitor, which causes cholinergic actions such a diaphroesis
D, the med is a cholinesterase inhibitor, which causes cholinergic actions such as anorexia,
nausea, vomiting, diarrhea, and abdominal pain which can lead to weight loss
A nurse is assessing a client who has been taking simvastatin and has alanine
aminotransferase (ALT) and aspartate aminotransferase (AST) elevations. Which of the
following findings is the nurse's priority assessment
A. Knowledge of the medication's adverse effects
B. Dietary intake of grapefruit
C. Changes in exercise routine
D. Recent weight gain - ANS-B
The greatest risk to this client is injury from liver damage due to elevated simvastatin levels,
finding out that the pt drinks grapefruit juice is priority. Grapefruit juice inhibits the drug
metabolizing enzyme and hepatic enzyme. The result is increased blood levels of stimvastatin
and the potential for serious adverse effects, such as elevated liver enzymes and
rhabdomyolysis (Potentially fatal disintegration of muscle tissue)
A nurse is assessing a client who has chronic pain disorder and is requesting pain medication.
Which of the following findings should the nurse identify as the most reliable indicator of the
client's pain
A. The client's behavior
B. Changes in the client's vital signs
C. The client's facial expression
D. The client's verbal report - ANS-D
The nurse should ask the client about the location, quality, and intensity of the pain
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate IV
therapy. A nurse should identify which of the following findings as an indication that the client is
having a therapeutic response
A. Increase in contractions
B. No seizure activity
C. No uterine bleeding
D. Decreased deep tendon reflexes - ANS-B
Magnesium sulfate is indicated to prevent seizures from preeclampsia or severe eclampsia
A nurse is assessing a client who is dehydrated. Which of the following findings is an indication
of hypokalemia
A. Muscle weakness
B. Hyperactive bowel sounds
, C. Positive Chvostek's sign
D. Red tongue - ANS-A
Weakness, fatigue, and lethargy are manifestations of hypokalemia
--
B, decreased bowel motility is a manifestation of hypokalemia. Hyperactive bowel sounds is a
manifestation of hyperkalemia
C, positive Chvosteks sign is a manifestation of hypocalcemia and hypomagnesemia
D, dry, swollen red tongue is manifestation of hypernatremia
A nurse is assessing a client who is receiving morphine via a patient controlled analgesia (PCA)
pump and finds the client sedated and difficult to arouse. Which of the following actions should
the nurse take
A. raise the head of the bed
B. Prepare to administer diphenhydramine
C. Decrease the demand dosage
D. Prepare to administer fulmazenil - ANS-A
Raise the head of the bed for a client who is difficult to arouse following opioid administration to
help improve ventilation
--
B, diphenhydramine is used to treat adverse effects, such as itching, and administer epinephrine
for anaphylaxis
C, the nurse should stop the PCA so that the client receives no further morphine and notify the
provider so adjustments can be made to the prescription
D, Flumazenil treats benzodiazepine toxicity. The nurse should prepare to administer naloxone,
an opiate antagonist, to a client who has opioid toxicity
A nurse is assessing a client who is receiving vincristine for the treatment of breast cancer.
Which of the following manifestations should the nurse identify as an adverse effect of the
medication
A. Hematuria
B. Numbness of fingers
C. Anxiety
D. Diarrhea - ANS-B
Vincristine can cause peripheral neuropathy, muscle atrophy, and numbness and tingling in the
hands and feet. Also can cause CNS depression, decreased reflexes, and motor difficulties
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