Adverse Reactions
Nursing Interventions
Calculations
Miscellaneous
Miscellaneous 2
100
A nurse is caring for a client who is receiving blood transfusion therapy. Which clinical manisfestations would alert the nurse to a hemolytic transfusion reaction? Select all that apply. 1. Headache 2. Tacycardia 3. Hypotension 4. Apprehension 5. Distended neck veins 6. A sense of impending doom
What is 1,2,3,4,6
100
Tranylcypromine (Parnate) is prescribed for a client with depression. The nurse instructs the client to avoid which food items? Select all that apply. 1. Figs 2. Apples 3. Avacado 4. Broccoli 5. Sauerkraut 6. Baked chicken
What is 1,3,5 (figs, avacado, and sauerkraut)
100
A physician prescribes: acetaminophen (Tylenol) liquid, 450mg orally every 4 hrs PRN for pain. The medication label reads: 160mg/5ml. The nurse prepares how many milliliters to administer one dose?
What is 14ml
100
A prenatal client is suspected of having iron deficiency anemia. Which finding should the nurse expect to note regarding the clients status? 1. Excess fluid volume 2. Deficient fluid volume 3. A low hemoglobin and hematocrit level 4. A high hemoglobin and hematocrit level
What is 3, A low hemoglobin and hematocrit level
100
A nurse is providing diet teaching to a client with congestive heart failure (CHF). The nurse tells the client to avoid which of the following? 1. Sherbet 2. Steak sauce 3. Apple juice 4. Leafy green vegetables
What is 2, Steak sauce
200
A client with myasthenia gravis is admitted to the hospital, and the nursing history reveals that the client is taking pyridostigmine (Mestinon). The nurse assess the client for side effects of the medication and asks the client about the presence of: 1. Mouth ulcers 2. Muscle cramps 3. Feelings of depression 4. Unexplained weight loss
What is 2, muscle cramps
200
A client with AIDS is admitted to the hospital for chills, fever, nonproductive cough, and pleuritic chest pain. A diagnoses of Pneumocystis jiroveci pneumonia is made and the client is started on IV pentamidine (Pentam-300). Which of the following should the nurse plan to carry out to safely administer the medication? 1. Infuse over 1 hr and allow the client to ambulate. 2. Infuse over 1 hr with the client in a supine position. 3. Administer over 30 minutes with the client in a reclining position. 4. Administer by IV push over 15 minutes with the client in a supine postition.
What is 2, Infuse over 1 hr with the client in a supine position.
200
The nurse hangs an IV bag of 1000ml of 5% dextrose in water (D5W) at 3pm and sets the flow rate to infuse at 75ml/hr. At 11pm, the nurse would expect the fluid remaining in the IV bag to be at approximately which level?
What is 400ml
200
A client has been taking an antihypertensive for approximately 2 months. A home care nurse monitoring the effects of therapy determines that drug tolerance has developed if which of the following is noted in the client? 1. Decrease in weight 2. Output greater than intake 3. Decrease in blood pressure 4. Gradual rise in blood pressure
What is 4, Gradual rise in blood pressure
200
The nurse is preparing to initiate an IV nitroglycerin drip on a client with acute MI. In the absence of an invasive (arterial) monitoring line, the nurse prepares to have which piece of equipment for use at the bedside? 1. Defibrillator 2. Pulse oximeter 3. Central venous pressure (CVP) tray 4. Noninvassive blood pressure monitor
What is 4, Noninvassive blood pressure monitor
300
A nurse is caring for a client with HTN receiving torsemide (Demadex) 5mg orally daily. Which of the following would indicate to the nurse that the client might be experiencing a side effect related to the medication? 1. A chloride level of 98 mEq/L 2. A sodium level of 135 mEq/L 3. A potassium level of 3.1 mEq/L 4. A blood urea nitrogen (BUN) of 15 mg/dL
What is 3, A potassium level of 3.1 mEq/L
300
The nurse assess a preoperative client. Which question should the nurse ask the client, to help determine the client's risk for developing malignant hyperthermia in the perioperative period? 1. "Have you ever had heat exhaustion or heat stroke?" 2. "What is the normal range for your body temperature?" 3. "Do you or any of your family members have frequent infections?" 4. "Do you or any of your family members have problems with general anesthesia?"
What is 4, "Do you or any of your family members have problems with general anesthesia?"
300
Your client has a prescription for digoxin (Lanoxin) 0.5mg orally every day. The tablets you have available are 0.25mg. How many tablets will you administer? 1. 1 tablet 2. 0.5 tablets 3. 2 tablets 4. 5 tablets
What is 3, 2 tablets
300
A nurse has just administered a purified protein derivative (PPD) skin test to a client who is at low risk for developing TB. The nurse determines that the test is positive if which of the following occurs? 1. An induration of 15mm 2. The presence of a wheal 3. A large area of erythema 4. Complaints of itching at the injection site
What is 1, An induration of 15mm
300
A nurse is assessing a client who is being treated with a beta-adrenergic blocker. Which assessment findings would indicate that the client may be experiencing dose-related side effects of the medications. Select all that apply. 1. Dizziness 2. Insomnia 3. Bradycardia 4. Reflex tachycardia 5. Sexual dysfunction 6. Cardiac dysrhythmias
What is 1,2,3, and 5 Dizziness, Insomnia, Bradycardia, and Sexual dysfunction
400
A nurse is performing an assessment on a client with a diagnoses of chronic angina pectoris who is receiving sotalol (Betapace) 80mg orally daily. Which assessment finding indicates that the client is experinceing a side effect of the medication. 1. Dry mouth 2. Palpitations 3. Diaphoresis 4. Difficulty swallowing
What is 2, Palpitations
400
A nurse has a prescription to administer hydroxyzine (Vistaril) to a client by the IM route. Before administering the medication, the nurse tells the client that: 1. Excessive salivation is a side effect 2. There will be some pain at the injection site 3. There will be relief from nausea within 5 minutes 4. The client will have increased alertness for about 2 hours
What is 2, There will be some pain at the injection site
400
Your client has a stat order for sodium amytal 0.1 g IM. The ampule contains 200mg/ 3ml. How much medication do you draw up in the syringe?
What is 1.5ml
400
A child is hospitalized with a diagnosis of lead posioning, and chelation therapy is prescribed. The nurse caring for the child would prepare to administer which of the following medications? 1. Ipecac syrup 2. Activated charcoal 3. Sodium bicarbonate 4. Calcium disodium edetate (EDTA)
What is 4, Calcium disodium edetate (EDTA)
400
A nurse is assessing the client with left-sided heart failure. The client states that he needs to use 3 pillows under the head and chest at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing: 1. Orthopnea 2. Dyspnea at rest 3. Dyspnea on excertion 4. Paroxysmal nocturnal dyspnea
What is 1, Orthopnea
500
A nurse is caring for a client who had an allogenic liver transplant and is receiving tacrolimus (Prograf) daily. Which finding indicates to the nurse that the client is experiencing and adverse reaction the the medication? 1. Hypotension 2. Photophobia 3. Profuse sweating 4. Decrease in urine output
What is 4, Decrease in urine output
500
An emergency department nurse prepares to treat a child with acetaminophen (Tylenaol) overdose. The nurse reviews the physician's prescriptions, expecting that which of the following will be prescribed? 1. Protamine sulfate 2. Succimer (Chemet) 3. Vitamin K (phytonadione) 4. acetylcysteine (Mucomyst)
What is 4, Acetylcysteine (Mucomyst)
500
A nurse is checking postoperative prescriptions and planning care for a 110-pound child after spinal fusion. Morphine sulfate, 8mg SC every 4 hours PRN for pain, is prescribed. The pediatric drug reference states that the safe dose is 0.1 to 0.2 mg/kg/dose every 2 to 4 hours. From this information, the nurse determines that: 1. The dose is too low 2. The dose is too high 3. The dose is within safe dosage range 4. There is not enough information to determine the safe dose.
What is 3, The dose is within safe dosage range
500
A physician tells a nurse that a client can be given ondansetron (Zofran) for relief of postoperative nausea. The nurse anticipates that the physician will most likely prescribe the medication by which of the following routes? 1. Oral 2. Intranasal 3. Intravenous 4. Subcutaneous
What is 3, Intravenous
500
The nurse understands that which of the following are clinical indicators for IV fluids? Select all that apply. 1. Syncope episodes 2. Bounding pulse rate 3. Chronic renal failure 4. Rapid, weak, and thready pulse 5. Serum electrolyte abnormalities 6. Abnormal serum and urine osmolality levels
What is 4, 5, and 6 Rapid, weak, and thready pulse; Serum electrolyte abnormalities, and Abnormal serum and urine osmolality levels
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