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A nurse is reinforcing teaching with a client who has a new prescription for a fluticasone inhaler. Which of the following client statements indicates an understanding of the teaching?

"I will rinse my mouth after I use this inhaler." The client should rinse their mouth after using inhaled glucocorticoids to reduce the risk for the development of oral thrush. Therefore, the nurse should identify this statement as indicating an understanding of the teaching.

A nurse in a community health clinic is preparing to administer the varicella vaccine to a young adult female client who has not previously had chickenpox or its vaccine. The nurse should withhold the vaccine and collect additional data when the client makes which of the following statements?

"I am allergic to neomycin." A hypersensitivity to neomycin is a contraindication for receiving the varicella vaccine.

A client who has terminal cancer reports pain as 5 on a scale of 0 to 10. The client has a prescription for morphine 15 mg orally every 4 hr. The client's adult children express concern that the client is receiving too much of the medication. Which of the following responses should the nurse make?

"The dose should remain constant to prevent breakthrough pain." Fixed or scheduled dosing around the clock offers the best pain control for clients who have severe and persistent pain.

A nurse is reinforcing teaching with a client who is to start therapy with a nitroglycerin transdermal patch. Which of the following statements by the client indicates an understanding of the teaching?

"While using the patch, I will be careful when rising from a chair." Nitroglycerin can cause orthostatic hypotension, which can result in dizziness. The client should change positions slowly to reduce the risk for injury.

A nurse is reviewing the medical record of a client who has a new prescription for dimenhydrinate to treat motion sickness. Which of the following conditions in the client's medical record should the nurse report to the provider?

Benign prostatic hyperplasia Clients who have benign prostatic hyperplasia might have urinary hesitancy and retention and, therefore, should not take dimenhydrinate due to the anticholinergic adverse effects of the medication.

A nurse is collecting data from a client who is taking oral amoxicillin to treat a respiratory infection. The nurse should monitor the client for which of the following manifestations as an adverse effect of the medication?

Diarrhea The nurse should monitor the client for diarrhea, which is an adverse effect of antibiotics, such as amoxicillin.

A nurse is collecting data from a client who has multiple sclerosis and a new prescription for baclofen. Which of the following findings should the nurse identify as an adverse effect of this medication?

Drowsiness The nurse should identify drowsiness as an adverse effect of baclofen. Other adverse effects include dizziness, weakness, and fatigue.

A nurse is reinforcing teaching with a client who is receiving enalapril 20 mg PO daily. The nurse should instruct the client to monitor for which of the following adverse effects of this medication?

Dry cough The nurse should identify that a persistent dry or nonproductive cough is an adverse effect of enalapril. The underlying cause of the dry cough is the accumulation of bradykinin from the medication. The client should notify the provider of this adverse effect.

A nurse is caring for a client who has a new prescription for risperidone to manage schizophrenia. Which of the following laboratory tests should the nurse plan to obtain prior to administering the first dose?

Fasting blood glucose level The development of hyperglycemia can be an adverse effect of risperidone. The nurse should obtain a fasting blood glucose level prior to administration of the first dose and periodically during treatment.

A nurse is reviewing the medication administration record of a client who has a history of Stevens-Johnson syndrome when taking sulfamethoxazole-trimethoprim. Which of the following medications should the nurse identify as contraindicated for this client?

Furosemide A client who has a history of Stevens-Johnson syndrome when taking sulfonamides is at risk for an allergic reaction to furosemide because the two medications are chemically related. The client should also avoid thiazide diuretics and sulfonylurea-type oral hypoglycemic agents.

A nurse is monitoring a client who has been receiving long-term hydrochlorothiazide therapy for recurring episodes of heart failure. Which of the following findings should the nurse identify as an adverse effect of this medication?

Hypokalemia Hydrochlorothiazide is a thiazide diuretic that can cause hypokalemia due to excessive potassium excretion in the urine.

A nurse is assisting with collecting data for a client who is in preterm labor and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse identify as an indication of magnesium toxicity?

Hyporeflexia Magnesium sulfate depresses neuromuscular activity, causing muscle weakness and paralysis. Therefore, the nurse should identify hyporeflexia as an indication of magnesium toxicity and report it to the charge nurse.

A nurse is evaluating a client who is receiving amphotericin B via intermittent IV bolus. Which of the following findings indicates an adverse reaction to this medication?

Hypotension The nurse should identify that amphotericin B is considered a high-alert medication due to potentially serious adverse effects, such as hypotension. Therefore, the nurse should report this or other adverse effects of amphotericin, such as nephrotoxicity, hypokalemia, and cardiac dysrhythmias.

A nurse is caring for a client who has a 10-year history of alcohol use disorder and is experiencing acute alcohol withdrawal. The nurse should identify which of the following interventions as the priority?

Implement seizure precautions. The greatest risk to the client is injury from seizures and falls. Grand mal seizures can occur during severe alcohol withdrawal. Therefore, the nurse's priority is to implement seizure precautions to reduce the risk of injury if the client experiences a seizure.

A nurse is reinforcing teaching with a client who recently began taking furosemide. Which of the following instructions should the nurse include in the teaching?

Increase dietary potassium while taking the medication. The nurse should reinforce with the client to increase dietary intake of potassium because furosemide causes potassium to be excreted in the urine. Increasing dietary potassium will help prevent hypokalemia.

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus about adverse effects of metformin. The nurse should instruct the client to monitor for which of the following findings as manifestations of lactic acidosis? (Select all that apply.)

Muscle pain Hyperventilation Dizziness Clients taking metformin should monitor for manifestations of lactic acidosis such as muscle pain, hyperventilation, and dizziness. Lactic acidosis is a severe adverse effect of metformin that the nurse should report to the provider immediately.

A nurse is collecting data from a client who is taking tobramycin. Which of the following findings should the nurse report to the provider immediately?

Oliguria Oliguria indicates the client is at greatest risk for nephrotoxicity. Therefore, the nurse should report this finding to the provider immediately.

A nurse is collecting data from a client who received morphine IV for pain relief. Which of the following findings is the nurse's priority to report to the provider?

Respiratory rate 11/min When using the airway, breathing, and circulation approach to client care, the priority finding is a respiratory rate of 11/min, which indicates respiratory depression.

A nurse is collecting data from a client who is taking lithium to treat bipolar disorder. Which of the following findings should the nurse report to the provider?

Slurred speech The nurse should recognize that slurred speech is a manifestation of lithium toxicity and should be reported to the provider.

A nurse is collecting data from a client who has been taking levodopa/carbidopa. Which of the following findings should indicate to the nurse that the medication is effective?

The client is able to wash their face. Levodopa works by activating dopamine receptors, restoring nerve transmission for clients who have Parkinson's disease. Carbidopa enhances these effects by inhibiting the breakdown of levodopa in the intestine and periphery. These therapeutic effects assist the client with moving freely and resuming ADLs.

A nurse is reinforcing dietary teaching with a client who has a new prescription for phenelzine. Which of the following foods should the nurse include in the teaching as an appropriate food choice?

Yogurt Clients taking phenelzine should avoid consuming tyramine, which can cause high blood pressure. Yogurt contains little or no tyramine. Therefore, the nurse should instruct the client that yogurt is an appropriate food choice.

A nurse is collecting data from a client who has bacterial pneumonia and is taking ceftriaxone. Which of the following findings indicates a therapeutic effect of the medication?

Clear, bilateral breath sounds The nurse should identify that wheezing and crackles are findings of bacterial pneumonia. A decrease in these manifestations indicates a therapeutic effect of the medication.

A nurse is collecting data from a client who has been taking digoxin for 1 month. The nurse should identify which of the following findings as a manifestation of digoxin toxicity?

Vomiting The nurse should identify vomiting as an early manifestation of digoxin toxicity.

A nurse is caring for a client who is receiving methylprednisolone. Which of the following laboratory values should the nurse plan to monitor? (Select all that apply.)

White blood cell count Serum potassium Blood glucose Methylprednisolone can increase the client's risk for infection and cause leukocytosis. Methylprednisolone can cause hypokalemia, as well as fluid and sodium retention. Methylprednisolone can cause increased blood glucose levels.


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