Nursing Elites

1. A client receiving nitrofurantoin (Macrodantin) calls the health care provider's office complaining of side effects related to the medication. Which side effect indicates the need to stop treatment with this medication?

• A. Nausea
• B. Diarrhea
• C. Anorexia
• D. Cough and chest pain

Correct answer: D

Rationale: Pulmonary reactions such as cough and chest pain are serious side effects associated with nitrofurantoin that require immediate discontinuation of the medication to prevent potential severe respiratory complications.

2. While assisting in caring for a pregnant client receiving intravenous magnesium sulfate for preeclampsia management, a nurse notes the client's absent deep tendon reflexes. What determination should the nurse make based on this data?

• A. The magnesium sulfate is effective.
• B. The infusion rate needs to be increased.
• C. The client is experiencing cerebral edema.
• D. The client is experiencing magnesium toxicity.

Correct answer: D

Rationale: When a pregnant client receiving intravenous magnesium sulfate for preeclampsia management exhibits absent deep tendon reflexes, this indicates magnesium toxicity. Magnesium toxicity can occur as a complication of magnesium sulfate therapy, leading to suppressed reflexes. It is crucial for the nurse to recognize this sign promptly and report it to prevent further complications or harm to the client.

3. A client with severe acne is seen in the clinic, and the healthcare provider prescribes isotretinoin. The nurse reviews the client's medication record and would contact the healthcare provider if the client is taking which medication?

• A. Vitamin A
• B. Digoxin (Lanoxin)
• C. Furosemide (Lasix)
• D. Phenytoin (Dilantin)

Correct answer: A

Rationale: Isotretinoin is a metabolite of vitamin A, which can lead to toxicity when taken together. Therefore, it is crucial to avoid concurrent use of vitamin A supplements with isotretinoin. Contacting the healthcare provider to discuss discontinuing vitamin A supplements is important to prevent potential adverse effects. Choices B, C, and D are incorrect as they are not known to interact significantly with isotretinoin.

4. A client is receiving morphine sulfate for pain management. Which assessment finding requires immediate action?

• A. Constipation
• B. Drowsiness
• C. Respiratory rate of 10 breaths per minute
• D. Nausea

Correct answer: C

Rationale: A respiratory rate of 10 breaths per minute indicates respiratory depression, a serious side effect of morphine sulfate that can lead to respiratory compromise and requires immediate intervention. Constipation, drowsiness, and nausea are common side effects of morphine but are not immediately life-threatening compared to respiratory depression. Monitoring and addressing a low respiratory rate are crucial in preventing further respiratory distress or failure.

5. The client has reinforced instructions for taking cholestyramine (Questran). Which statement indicates a need for further instructions?

• A. I will continue taking vitamin supplements.
• B. This medication will help lower my cholesterol.
• C. This medication should only be taken with water.
• D. A high-fiber diet is important while taking this medication.

Correct answer: C

Rationale: The correct answer is C because cholestyramine should not only be taken with water. Flavored products or fruit juices can improve the taste. Choices A, B, and D are all correct statements. It is important for the client to continue taking vitamin supplements, understand that cholestyramine helps lower cholesterol, and maintain a high-fiber diet while taking this medication to enhance its effectiveness.

Similar Questions