ATI Pharmacology 2023 Assessment B

The nurse is caring for a client in a mental health clinic.

Provider Prescriptions

​

1230:

Bupropion XR 150 mg daily once daily in AM for three days then increase to 150 mg twice daily.

Assessment

​

1200:

Client here for scheduled visit to discuss mood. Client reports they were previously prescribed sertraline for depression, however tapered off that medication 6 months ago. Client states "It made me gain weight and it completely took away my sex drive, so I stopped taking it." The client reports "My depression has just gotten so bad. I have been seeing a counselor and they encouraged me to see a provider about trying a different medication."

1230:

Provider Prescriptions received. Visit summary reviewed with client to discuss the newly prescribed medication. Client has a follow-up visit with provider in 3 weeks and continues with weekly counseling.

For each body system below, click to specify the adver

Genitourinary- changes in libido

GI- constipation metabolic- wt loss

Rationale:

When taking action, the nurse should educate the client about potential adverse effects of bupropion. Common adverse effects of this medication include changes in libido, constipation, and weight loss.

A nurse is caring for a client in a clinic.

Nurses' Notes

3 months ago:

Client was educated on non-pharmacological interventions to lower blood pressure such as exercise and a low-fat, low-sodium diet with fresh fruits and vegetables. Client to return to office for a follow-up visit in 3 months.

Today:

Blood pressure is still elevated. Provider notified and prescription given to the client. The client was educated on the medication.

Vital Signs

3 months ago:

Temperature 36.7° C (98° F)

Pulse 75/min

Respiratory Rate 16/min

Blood Pressure 130/81 mm Hg

Oxygen Saturation 99% on room air

Today:

Temperature 36.4° C (97.5° F)

Pulse 77/min

Respiratory Rate 16/min

Blood Pressure 148/90 mm Hg

Oxygen Saturation 98% on room air

Provider Prescriptions

Today:

Captopril 12.5 mg twice a day by mouth

Which client statements indicate an understanding of the teaching? Click to specify if the client statement indicates an underst

"I will notify my provider if I feel sick."-Understanding

"I will eat foods high in potassium."

-Need for further education

"I should take this medication with meals."

-Need for further education

"Coughing is expected while taking this medication."-Need for further education

"I should take acetaminophen instead of ibuprofen for a headache." -Understanding

Rationale:

When evaluating outcomes, the nurse should identify that the client's statements: "I will notify my provider if I feel sick" and "I should take acetaminophen instead of ibuprofen for a headache" indicate an understanding of teaching. Captopril can cause neutropenia. If a client develops manifestations of infection such as a fever or sore throat, the provider should be notified. NSAIDS such as ibuprofen may reduce the effectiveness of captopril and should be avoided. The nurse should identify that the client's statements: "I will eat foods high in potassium," "Coughing is expected while taking this medication," and "I should take this medication with meals indicate a need for further education. Hyperkalemia is an adverse effect of captopril. The client should avoid potassium supplements and potassium-sparing supplements. Coughing is an adverse effect of captopril and the nurse should notify the provider. Captopril should be given one hour before meals or two hours after meals.

A nurse is caring for a client in a clinic and is reviewing their electronic medical record (EMR).

Nurses' Notes

3 months ago:

Client was prescribed atorvastatin by provider. Client was educated to continue eating a diet low in saturated fats and to participate in regular exercise. Client is to return to the office in 3 months for a follow-up visit.

Today:

Client here for a follow-up visit. Client reports last bowel movement was 1 day ago, increased appetite, and dark urine upon urination. Client reports having some muscle weakness when working outside. Skin is warm, dry, and intact. Color consistent with genetic background. Client states, "I am sleeping so much better and seem to have increased energy, but I sometimes get lightheaded." Client denies headache. Will report assessment findings to the provider.

Provider Prescriptions

3 months ago:

Atorvastatin 40 mg once daily by mouth

For each body system below, cli

Gastrointestinal/Genitourinary- urine characteristics

Musculoskeletal/Integumentary- muscle weakness

Neurological- dizziness

Rationale:

When recognizing cues for a client who is taking atorvastatin, the nurse should identify that the findings of the client's urine characteristics, muscle weakness, and dizziness indicate an adverse reaction to the medication. Atorvastatin can cause dark urine, muscle pain, muscle spasms, and weakness, which could be an indication of injury to the muscle tissue. Atorvastatin can also cause neurological symptoms such as dizziness, headache, confusion, and fatigue.

A nurse is preparing to administer PO sodium polystyrene sulfonate to a client who has hyperkalemia. Which of the following actions should the nurse plan to take?

A. Hold the client's other oral medications for 8 hr post administration.

B. Inform the client that this medication can turn stool a light tan color.

C. Keep the client's solution in the refrigerator for up to 72 hr.

D. Monitor the client for constipation.

D. Monitor the client for constipation.

Rationale:

-The nurse should monitor the client for the adverse effect of constipation and report it to the provider because this can lead to fecal impaction.

-The nurse should hold the client's other oral medications for 6 hr before and after administration of sodium polystyrene sulfonate.

-Sodium polystyrene sulfonate will not alter the color of the client's stool.

-Sodium polystyrene sulfonate solution is stable for 24 hr when refrigerated.

A nurse is planning care for a client who has hypertension and is to start taking metoprolol. Which of the following interventions should the nurse include in the plan of care?

A. Weigh the client weekly.

B. Determine apical pulse prior to administering.

C. Administer the medication 30 min prior to breakfast.

D. Monitor the client for jaundice.

B. Determine apical pulse prior to administering.

Rationale:

Life-threatening bradycardia is an adverse effect that might affect this client. Therefore, the nurse should assess the client's apical pulse prior to administering the medication. If the client's pulse rate is less than 60/min, the nurse should withhold the medication and notify the provider.

The nurse should weigh the client daily to monitor for the development of heart failure and weight gain.

The nurse should administer metoprolol following meals or at bedtime if orthostatic hypotension occurs.

The nurse should monitor the client for adverse effects, such as hypotension. However, jaundice is not associated with this medication.

A nurse is reviewing the electronic medical record for a client who is receiving heparin via continuous IV infusion for deep vein thrombosis. Which of the following findings should the nurse identify as an adverse effect of heparin that requires notification of the provider?

A. Urinary frequency

B. Xerostomia

C. Diplopia

D. Generalized petechiae

D. Generalized petechiae

Rationale:

The nurse should identify that generalized petechiae is an indication of thrombocytopenia, which is a potential adverse effect of heparin. The client is at an increased risk for hemorrhage, which can be fatal. Therefore, the nurse should notify the provider of this finding.

Urinary frequency is an indication of urinary tract infection, which is not an adverse effect of heparin. Therefore, this finding does not require notification of the provider.

Xerostomia, or dry mouth, is not an adverse effect of heparin. Therefore, this finding does not require notification of the provider.

Diplopia, or double vision, is not an adverse effect of heparin. Therefore, this finding does not require notification of the provider.

A nurse is assessing a client who is postoperative following an outpatient endoscopy procedure using midazolam. The nurse should monitor for which of the following findings as an indication that the client is ready for discharge?

A. The client's capnography has returned to baseline.

B. The client can respond to their name when called.

C. The client is passing flatus.

D. The client is requesting oral intake.

A. The client's capnography has returned to baseline.

Rationale:

The nurse should identify that the client is ready for discharge when the capnography level indicates that gas exchange is adequate.

The client is considered ready for discharge when the state of arousal is at the preprocedure level.

The nurse should monitor for the passing of flatus for a client who received general anesthesia.

A request for oral intake does not indicate the client is ready for discharge. The nurse should assess for a return of the gag reflex for a client who is postoperative following an endoscopy.

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

D. Dyspnea

Rationale:

When using the airway, breathing, circulation approach to client care, the nurse should report the adverse effect of dyspnea, caused by bronchoconstriction, to the provider first. Bronchoconstriction, dyspepsia, diarrhea, and dizziness are caused by the increase in acetylcholine levels, which is a primary effect of donepezil.

The nurse should report dyspepsia to the provider because dyspepsia can cause discomfort and irritation to the esophageal tissues. However, the nurse should report another finding first.

The nurse should report diarrhea to the provider because diarrhea can result in electrolyte and fluid imbalances. However, the nurse should report another finding first.

The nurse should report dizziness to the provider because dizziness can place the client at an increased risk for falls. However, the nurse should report another finding first.

A nurse is assessing a client who is taking propylthiouracil for the treatment of Graves' disease. Which of the following findings should the nurse identify as an indication that the medication has been effective?

A. Decrease in WBC count

B. Decrease in amount of time sleeping

C. Increase in appetite

D. Increase in ability to focus

D. Increase in ability to focus

Rationale:

A client who has Graves' disease can experience psychological manifestations such as difficulty focusing, restlessness, and manic-type behaviors. Propylthiouracil is a thyroid hormone antagonist that decreases the circulating T4 hormone, reducing the manifestations of hyperthyroidism. An increased ability to focus indicates that the medication has been effective.

Propylthiouracil is a thyroid hormone antagonist used in the treatment of hyperthyroidism, or thyroid storms. A decreased WBC count is an adverse effect of propylthiouracil, which can cause myelosuppression. Therefore, a decrease in WBC count indicates the medication has not been effective.

Graves' disease, a form of hyperthyroidism, has neurologic manifestations, including insomnia. Therefore, a decrease in the amount of time sleeping indicates the medication has not been effective.

Graves' disease can result in gastrointestinal manifestations such as increased appetite, weight loss, and increased gastrointestinal motility. Therefore, an increase in appetite indicates the medication has not been effective.

A nurse is collecting a medication history from a client from a client who has a new prescription for lithium. Which of the following over-the-counter medications should the nurse identify as needing to be discontinued by the client?

A. Aspirin

B. Ibuprofen

C. Famotidine

D. Bisacodyl

B. Ibuprofen

Rationale:

Most NSAIDs can significantly increase lithium levels. Therefore, the client should not take ibuprofen and lithium concurrently.

Although most NSAIDs interact with lithium to increase lithium levels, aspirin does not interact with lithium.

There are no known medication interactions between famotidine and lithium.

There are no known medication interactions between bisacodyl and lithium.

A nurse is caring for a client who has developed hypomagnesemia due to long-term therapy with Lansoprazole. The nurse should monitor the client for which of the following manifestations?

A. Bradycardia

B. Hypotension

C. Muscle weakness

D. Disorientation

D. Disorientation

Rationale:

The nurse should monitor the client for disorientation and confusion as manifestations of hypomagnesemia. The nurse should also assess the client for a positive Chvostek's and Trousseau's signs.

The nurse should monitor the client for neuromuscular irritability, such as tremors, as a manifestation of hypomagnesemia.

The nurse should monitor the client for hypertension as a manifestation of hypomagnesemia.

The nurse should monitor the client for tachycardia as a manifestation of hypomagnesemia.

A nurse is providing teaching to a client who has a new prescription for ferrous sulfate. The nurse should instruct the client to take the medication with which of the following to promote absorption?

A. Vitamin E

B. Orange juice

C. Milk

D. Antacids

B. Orange juice

Rationale:

The absorption of ferrous sulfate is enhanced by a vitamin C source, such as orange juice.

Vitamin E has no effect on iron absorption.

Milk inhibits iron absorption.

Antacids inhibit iron absorption.

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

D. Miosis

D. Miosis

Rationale:

Miosis, which is pupillary constriction, is a common adverse effect of neostigmine due to the excessive muscarinic stimulation that causes difficulty with visual accommodation.

Neostigmine can cause bradycardia, rather than tachycardia, due to the excessive muscarinic stimulation.

Neostigmine can cause urinary urgency, rather than decreased urinary output, due to the excessive muscarinic stimulation.

Neostigmine can cause increased salivation, rather than dry mouth, due to the excessive muscarinic stimulation.

A nurse is developing a teaching plan for a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include in the teaching plan? (Select all that apply.)

1. Report muscle pain to the provider.2. Avoid taking the medication with grapefruit juice.3. Expect therapy with this medication to be lifelong.

Rationale:

Report muscle pain to the provider is correct. Myopathy is an adverse effect of simvastatin that can lead to rhabdomyolysis. The nurse should instruct the client to report this to the provider.

Avoid taking the medication with grapefruit juice is correct. When taken with grapefruit juice, simvastatin increases the risk of muscle injury from elevations in creatine kinase.

Take the medication in the early morning is incorrect. This medication is most effective when taken in the evening because cholesterol production generally increases overnight.

Expect a flushing of the skin as a reaction to the medication is incorrect. The nurse should identify flushing of the skin as an adverse effect of the medication niacin, which can be used to decrease the client's triglyceride levels.

Expect therapy with this medication to be lifelong is correct. If medication therapy is discontinued, cholesterol levels will return to their pretreatment range within several weeks to months.

A nurse is caring for a client who reports lethargy and myalgia after taking clozapine for 6 months. Which of the following actions should the nurse plan to take?

A. Infuse 0.9% sodium chloride 1,000 mL IV fluid bolus.

B. Schedule the client for an electroencephalogram.

C. Obtain WBC with absolute neutrophil count.

D. Place the client on a tyramine-free diet.

C. Obtain WBC with absolute neutrophil count.

Rationale:

The client who takes clozapine can develop lethargy and myalgia caused by the adverse effect of agranulocytosis. Therefore, monitoring the WBC with absolute neutrophil count weekly for the first 6 months of treatment is recommended. After 6 months, monitoring can occur every 2 weeks up to 1 year.

The client who is dehydrated can receive 0.9% sodium chloride IV bolus, but it is not used to treat the adverse effects of lethargy, myalgia, and weakness associated with clozapine.

The client who develops seizures can have an electroencephalogram, but it is not used to treat or diagnose the client who has lethargy and myalgia.

The client can take clozapine with or without food and does not need to follow a tyramine-free diet. A client who is taking monoamine oxidase inhibitors should follow a tyramine-free diet.

A nurse is providing teaching to a client who is taking bupropion for smoking cessation. Which of the following findings should the nurse identify as an adverse effect of the medication?

A. Cough

B. Joint pain

C. Alopecia

D. Insomnia

D. Insomnia

Rationale:

Bupropion, an atypical antidepressant, has stimulant properties which can result in agitation, tremors, mania, and insomnia.

Bupropion, an atypical antidepressant, does not cause coughing.

Bupropion can cause neurologic adverse effects such as bradykinesia. However, it does not cause joint pain.

Bupropion can cause sensory adverse effects such as changes in vision and hearing. However, it does not cause alopecia.

A nurse is teaching a client who is scheduled for a colonoscopy and has a prescription for polyethylene glycol-electroyle solution and bisacodyl. Which of the following statements should the nurse make?

A. "Expect a bowel movement 2 hr following the first dose of the bowel cleanser."

B. "Plan to drink 2 liters of the bowel cleanser solution."

C. "Plan to drink 1 large glass of red cranberry juice the day before the procedure."

D. "Expect to drink the bowel cleanser solution over an 8 hr period."

B. "Plan to drink 2 liters of the bowel cleanser solution."

Rationale:

The nurse should instruct the client to drink 240 mL (8 oz) of the bowel cleanser solution every 10 min until 2 L (67.6 oz) are consumed.

A nurse is administering digoxin immune Fab to a client following a medication error. Which of the following findings should the nurse identify as an indication that the medication was effective?

A. Sinus rhythm

B. A decrease in the platelet count

C. An increase in the alanine transaminase (ALT) level

D. Deep tendon reflexes 2+

A. Sinus rhythm

Rationale:

Digoxin immune Fab is the antidote for digoxin toxicity. Dysrhythmias are a life-threatening adverse effect of digoxin toxicity. Therefore, the return of the client's heart to a sinus rhythm indicates a therapeutic response to the antidote, digoxin immune Fab.

A decrease in the client's platelet count is not evidence of a therapeutic response to digoxin immune Fab, the antidote for digoxin toxicity.

A decrease in the client's ALT level is not evidence of a therapeutic response to digoxin immune Fab, the antidote for digoxin toxicity.

Deep tendon reflexes 2+ is not evidence of a therapeutic response to digoxin immune Fab, the antidote for digoxin toxicity.

A nurse is teaching a client about warfarin. The client asks if they can take aspirin while taking warfarin. Which of the following responses should the nurse make?

A. "It is safe to take an enteric-coated aspirin."

B. "The INR lab work must be monitored more frequently if aspirin is taken."

C. "Acetaminophen may be substituted for aspirin."

D. "Aspirin will increase the risk of bleeding."

D. "Aspirin will increase the risk of bleeding."

Rationale:

Aspirin inhibits platelet aggregation and can potentiate the action of the anticoagulant warfarin. Therefore, the client should avoid taking aspirin because it increases the risk for bleeding.

Although it is common for clients to consider an occasional aspirin harmless, salicylates inhibit platelet aggregation and increase the potential for hemorrhage. Therefore, the client should avoid taking enteric-coated aspirin.

The client should continue to follow the provider's prescription for monitoring the PT and INR levels to adjust warfarin dosages. However, the nurse should discourage the client from using aspirin products because these medications increase the antiplatelet action of the warfarin and can result in bleeding.

Acetaminophen, an analgesic, can potentiate the action of the anticoagulant warfarin when administered in high doses and is not a safe substitute for aspirin.

A nurse is preparing to administer 0.9% sodium chloride 1,500 mL to infuse over 8 hr to a client who is postoperative. How many mL/hr should the nurse set the IV pump to deliver?

188 mL/hr

Rationale:

Step 1: What is the unit of measurement the nurse should calculate? mL/hr

Step 2: What is the volume the nurse should infuse? 1,500 mL

Step 3: What is the total infusion time? 8 hr

Step 4: Should the nurse convert the units of measurement? No

Step 5: Set up an equation and solve for X.

Volume (mL)X mL/hr = Time (hr)

1,500 mLX mL/hr = 8 hr

X mL/hr = 187.5 mL/hr

Step 6: Round if necessary. 187.5 mL/hr = 188 mL/hr

Step 7: Determine whether the amount to administer makes sense. If the prescription reads 1,500 mL 0.9% sodium chloride IV to infuse over 8 hr, it makes sense to administer 188 mL/hr. The nurse should set the IV pump to deliver 0.9% sodium chloride IV at 188 mL/hr.

A nurse is caring for the parent of a newborn. The parent asks the nurse when their newborn should receive the first diphtheria, tentanus, and pertussis vaccine (DTap). Which of the following ages should the nurse advise the parent to immunize their newborn?

A. At birth

B. 6 months

C. 2 months

D. 15 months

C. 2 months

Rationale:

The CDC recommends that newborns receive the first dose of the five-dose series of the DTaP immunization at 2 months of age.

A nurse at a clinic is providing follow-up care for 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. Absence of dreams

C. Sexual dysfunction

D. Pica

C. Sexual dysfunction

Rationale:

Sexual dysfunction, including a decreased 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.

Fluoxetine is an SSRI that can cause muscle twitching. However, distorted sensations in the extremities are not adverse effects of fluoxetine.

Fluoxetine can cause CNS adverse effects including abnormal dreaming, sedation, delusions, hallucinations, and psychosis. However, an absence of dreams is not associated with fluoxetine.

Fluoxetine can cause neurologic adverse effects such as agitation, euphoria, and sedation. However, an eating disorder such as pica is not associated with fluoxetine.

A nurse is teaching a client who is starting to teak amitriptyline. Which of the following findings should the nurse include in the teaching as an adverse effect of the medication?

A. Muscle twitching

B. Cough

C. Urinary retention

D. Increased libido

C. Urinary retention

Rationale:

The nurse should instruct the client that amitriptyline causes the anticholinergic effect of urinary retention.

A nurse receives a verbal order from the provider to administer morphine five milligrams every 4 hours subcutaneously for severe pain as needed. The nurse should identify which of the following entries as the correct format for the medication administration record (MAR)?

A. MSO4 5 mg subcut every 4 hr PRN severe pain

B. Morphine 5 mg subcut every 4 hr PRN severe pain

C. MSO4 5 mg SQ every 4 hr PRN severe pain

D. Morphine 5.0 mg subcutaneously every 4 hr PRN severe pain

B. Morphine 5 mg subcut every 4 hr PRN severe pain

Rationale:

The nurse should identify this entry as the correct format for the MAR. The medication name is spelled out and there are not any abbreviations from The Joint Commission's "Do Not Use" list included in the transcription.

A nurse is reviewing the medical record of a client who has hypertension. The nurse should identify which of the following findings as a contraindication for receiving propranolol?

A. Cholelithiasis

B. Asthma

C. Angina pectoris

D. Tachycardia

B. Asthma

Rationale:

Asthma is a contraindication for receiving propranolol. Propranolol is an adrenergic antagonist that blocks the beta2 receptors in the lungs, causing bronchoconstriction and leading to serious airway resistance and possibly respiratory arrest.

The client who has angina pectoris can receive propranolol to decrease heart rate and contractility, resulting in a reduction of oxygen demand. Propranolol is contraindicated for use when a client has vasospastic angina.

Tachycardia is not a contraindication for receiving propranolol. Propranolol is administered to slow a client's heart rate and decrease oxygen demand.

A nurse is planning to administer IV midazolam for a client who is receiving moderate sedation. Which of the following actions should the nurse plan to take?

A. Ensure that naloxone is available in the event of toxicity.

B. Administer the midazolam over one minute.

C. Expect the client's respiratory rate to increase.

D. Expect the client to respond to simple commands.

D. Expect the client to respond to simple commands.

Rationale:

The nurse should expect the client to maintain spontaneous respirations and respond to simple commands.

The nurse should administer the midazolam over 2 to 5 min to reduce the risk of adverse effects, such as hypotension.

The nurse should have flumazenil available to reverse the effects of midazolam.

The nurse should monitor the client for respiratory depression.

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

C. Flumazenil

Rationale:

The nurse should anticipate administering flumazenil, an antidote used to reverse benzodiazepines such as diazepam.

Ondansetron is an antiemetic that is used to treat nausea and vomiting.

Magnesium sulfate is an electrolyte replacement that is used to treat clients who are at risk for seizure activity.

Protamine sulfate is an antidote for heparin and is used to reverse an elevated aPTT caused by taking heparin.

A nurse is caring for a client who is taking acetazolamide for chronic open-angle glaucoma. Which of the following adverse effects should the nurse instruct the client to monitor for and report to the primary care provider?

A. Tingling of fingers

B. Constipation

C. Weight gain

D. Oliguria

A. Tingling of fingers

Rationale:

The nurse should instruct the client to report the adverse effect of paresthesia, a tingling sensation in the extremities, when taking acetazolamide.

Diarrhea is an adverse effect of acetazolamide due to gastrointestinal disturbances.

Weight loss is an adverse effect of acetazolamide due to gastrointestinal disturbances causing reduced appetite.

Polyuria, rather than oliguria, is an adverse effect of acetazolamide.

A nurse is providing teaching to a client who is to start taking sumatriptan. Which of the following adverse effects should the nurse instruct the client to monitor for and report to the provider?

A. Chest pressure

B. White patches on the tongue

C. Bruising

​D. Insomnia

A. Chest pressure

Rationale:

Sumatriptan is an antimigraine agent that can cause coronary vasospasms, resulting in angina. The client should report chest pressure or heavy arms to the provider.

White patches on the tongue can indicate a fungal infection, which is not an adverse effect of sumatriptan.

Ecchymosis can indicate thrombocytopenia, which is not an adverse effect of sumatriptan.

Sumatriptan can cause drowsiness and sedation as an adverse effect of the medication.

A nurse is caring for a client who is receiving heparin therapy via continuous IV infusion to treat a pulmonary embolism. Which of the following findings should the nurse identify as an adverse effect of the medication and report to the provider?

A. Vomiting

B. Blood in the urine

C. Positive Chvostek's sign

D. Ringing in the ears

B. Blood in the urine

Rationale:

The nurse should report blood in the urine to the provider because this can be a manifestation of heparin toxicity. Other manifestations can include bruising, hematomas, hypotension, and tachycardia.

Vomiting is not an expected adverse effect of heparin therapy. The nurse should assess the client for other causes of vomiting.

A Chvostek's sign is seen in clients who have hypocalcemia or hypomagnesemia.

Ringing in the ears is not an expected adverse effect of heparin therapy. Aminoglycosides, such as vancomycin, are medications that cause ringing in the ears.

A nurse is caring for a client who has cancer and is prescribed oral morphine and docusate sodium. Which of the following adverse effects of morphine should the nurse instruct the client can be minimized by taking daily docusate sodium?

A. Constipation

B. Drowsiness

C. Facial flushing

D. Itching

A. Constipation

Rationale:

Constipation is a common adverse effect of morphine that can be minimized by taking docusate sodium, a stool softener that promotes easier evacuation of stool by increasing water and fat in the intestine.

Drowsiness is not an adverse effect of morphine that can be minimized by taking docusate sodium.

Facial flushing is not an adverse effect of morphine that can be minimized by taking docusate sodium.

Itching is not an adverse effect of morphine that can be minimized by taking docusate sodium.

A nurse is caring for a client who is refusing to take their scheduled morning furosemide. Which of the following statements should the nurse make?

A."If you do not take your furosemide, we might get in trouble."

B."You can double your dose of furosemide this evening if that would be better for you."

C."By not taking your furosemide, you might retain fluid and develop swelling."

D."I'll go ahead and mix the furosemide into your breakfast cereal."

C."By not taking your furosemide, you might retain fluid and develop swelling."

Rationale:

The nurse should respect the client's right to refuse the medication and inform the client of the risks of not taking the medication, notify the provider, and document the refusal. Furosemide is a loop diuretic given to reduce edema.

A nurse is caring for a client who received 0.9% sodium chloride 1 L over 4hr instead of over 8 hr as prescribed. Which of the following information should the nurse enter as a complete documentation of the incident?

A. IV fluid infused over 4 hr instead of the prescribed 8 hr. Client tolerated fluids well, provider notified.

B. 1 L of 0.9% sodium chloride completed at 0900. Client denies shortness of breath.

C. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.

D. IV fluid initiated at 0500. Lungs clear to auscultation.

C. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.

Rationale:

The nurse should document the type and amount of fluid, how long it took to infuse, provider notification, and the client's physical status.

A nurse on the acute care unit is caring for a client who is receiving gentamicin IV. Which of the following findings should the nurse report to the provider as an adverse effect of the medication?

A. Constipation

B. Hypoglycemia

C. Tinnitus

D. Joint pain

C. Tinnitus

Rationale:

Aminoglycosides, such as gentamicin, are ototoxic, which can manifest as tinnitus and deafness. The nurse should monitor the client for high-pitched ringing in the ears and headaches and should notify the provider if these occur.

A nurse is caring for a client who is taking atorvastatin for hyperlipidemia. Which of the following client laboratory values should the nurse monitor?

A. Creatinine kinase

B. Erythrocyte sedimentation rate

C. International normalized ratio

D. Potassium

A. Creatinine kinase

Rationale:

The client who is taking atorvastatin can develop an adverse effect called rhabdomyolysis, which causes muscle weakness or pain and can progress to myositis. Creatinine kinase levels rise in response to enzymes released with muscle injury.

A nurse is reviewing assessment findings for a client who has a new prescription for ceftazidime via intermittent IV bolus. Which of the following findings should the nurse identify as a contraindication to this medication?

A. Increased WBC count

B. Allergy to lamotrigine

C. Increased LDL level

D. Allergy to cephalosporins

D. Allergy to cephalosporins

Rationale:

Ceftazidime is a third generation cephalosporin antibiotic. An allergy to cephalosporins is a contraindication to the administration of ceftazidime. Therefore, the nurse should not administer the medication and report this allergy to the provider.

A nurse is administering cefotetan via intermittent IV bolus to a client who suddenly develops dyspnea and widespread hives. Which of the following actions should the nurse take first?

A. Administer epinephrine 0.5 mL via IV bolus.

B. Discontinue the medication IV infusion.

C. Elevate the client's legs above the level of the heart.

D. Collect a blood specimen for ABGs.

B. Discontinue the medication IV infusion.

Rationale:

The greatest risk to the client is respiratory arrest from anaphylaxis. Therefore, the first action the nurse should take is to discontinue the medication IV infusion to prevent the client from receiving more medication. However, the nurse should not remove the IV catheter. Instead, the nurse should change the tubing and administer 0.9% sodium chloride by continuous IV infusion.

The nurse should administer epinephrine, which is a beta-adrenergic agonist that can stimulate the heart, cause vasoconstriction of blood vessels in the skin and mucous membranes, and cause bronchodilation in the lungs. However, there is another action the nurse should take first.

The nurse should elevate the client's legs and feet to a level above the client's heart to facilitate blood flow to the vital organs. However, there is another action the nurse should take first.

The nurse should collect a blood specimen for ABGs levels to evaluate the client's respiratory status. However, there is another action the nurse should take first.

A nurse is providing teaching to a client who has a prescription for trimethoprim/sulfamethoxazole. Which of the following instructions should the nurse include in the teaching?

A. Take the medication with food.

B. Expect a fine, red rash as a transient effect.

C. Drink 8 to 10 glasses of water daily.

D. Store the medication in the refrigerator.

C. Drink 8 to 10 glasses of water daily.

Rationale:

The nurse should instruct the client to increase water intake to 1,920 to 2,400 mL (65 to 81 oz) a day to decrease the chance of kidney damage from crystallization.

The nurse should instruct the client to take the medication on an empty stomach either 1 hr before or 2 hr after meals.

The nurse should instruct the client to notify the provider if a rash develops, because this can be an indication of Stevens-Johnson syndrome. However, the client should not expect to have a fine, red rash as a transient effect.

The nurse should inform the client to store trimethoprim/sulfamethoxazole in a light-resistant container at room temperature.

A nurse administers ceftazidime to a client who has severe penicillin allergy. The nurse should identify which of the following client findings as an indication they should complete an incident report?

A. The client reports shortness of breath.

B. The client is also taking lisinopril.

C. The client's pulse rate is 60/min.

D. The client's WBC count is 14,000/mm3 (5,000 to 10,000/mm3).

A. The client reports shortness of breath.

Rationale:

A severe penicillin allergy is a contraindication for taking ceftazidime, a cephalosporin antibiotic, due to the potential for cross-sensitivity. Shortness of breath can indicate the client is developing anaphylaxis.

Lisinopril is an ACE inhibitor medication that has no known interaction with cephalosporins.

Cephalosporins do not affect the client's pulse rate. The client's pulse rate of 60/min is within the expected reference range.

An elevated WBC count is an indication the client has an infection and should receive antibiotic therapy.

A nurse is caring for a client who has heart failure and a prescription for enalapril. Which of the following findings as an adverse effects of the medication should the nurse monitor the client for?

A. Bradycardia

B. Hyperkalemia

C. Loss of smell

D. Hypoglycemia

B. Hyperkalemia

Rationale:

Enalapril improves cardiac functioning in clients who have heart failure and can cause hyperkalemia due to potassium retention by the kidneys.

Enalapril is an ACE inhibitor that has several cardiovascular adverse effects including hypotension, tachycardia, and dysrhythmias.

Enalapril can cause several sensory adverse effects, such as a loss of taste. However, it does not cause a loss of smell.

Enalapril does not cause hypoglycemia.

A nurse is reviewing the assessment findings of a client who is taking carbamazepine for a seizure disorder. Which of the following findings should the nurse report to the provider as an adverse effect of carbamazepine?

A. Hypersalivation

B.Dysuria

C. An increased uric acid level

D. A decreased WBC count

D. A decreased WBC count

Rationale:

Leukopenia, or a decreased WBC count, is an adverse effect of carbamazepine. The nurse should report this finding to the provider and monitor the client for manifestations of infection.

Xerostomia, or dry mouth, is a potential adverse effect of carbamazepine. Other potential adverse effects include constipation and decreased appetite.

Dysuria, or pain with urination, can indicate a urinary tract infection. However, it is not a potential adverse effect of carbamazepine.

An increased uric acid level can indicate renal disease, acidosis, or certain types of cancers. However, it is not a potential adverse effect of carbamazepine.

A nurse is caring for a client who has diabetes mellitus and is taking glyburide. The client reports feeling confused and anxious. Which of the following actions should the nurse take first?

A. Perform a capillary blood glucose test.

B. Provide the client with a protein-rich snack.

C. Give the client 120 mL (4 oz) of orange juice.

D. Schedule an early meal tray.

A. Perform a capillary blood glucose test.

Rationale:

The greatest risk to this client is injury from hypoglycemia. Therefore, the nurse should perform a capillary blood glucose test to determine the client's blood glucose status. Manifestations of hypoglycemia include weakness, anxiety, confusion, sweating, and seizures.

The nurse should provide the client with a protein-rich snack after determining the client's blood glucose value and providing a carbohydrate first. However, there is another action that the nurse should take first.

The nurse should give the client 10 to 15 g of carbohydrates, such as 4 oz of orange juice, to treat hypoglycemia. However, there is another action that the nurse should take first.

The nurse should schedule an early meal tray to maintain the client's blood glucose level following the initial interventions for hypoglycemia. However, there is another action the nurse should take first.

A nurse in the emergency department is caring for a client who has heroin toxicity. The client is unresponsive with pinpoint pupils and a respiratory rate of 6/min. Which of the following medication should the nurse plan to administer?

A. Methadone

B. Bupropion

C. Diazepam

D. Naloxone

D. Naloxone

Rationale:

The nurse should administer naloxone, an opioid antagonist, to a client who has heroin toxicity to reverse the respiratory depressive effects of the heroin. However, the nurse should not administer naloxone too quickly because naloxone can cause hypertension, tachycardia, nausea, vomiting, and might cause the client to enter a state of opioid withdrawal.

The nurse should administer methadone, an opioid agonist, to a client who has heroin toxicity to decrease manifestations of opioid withdrawal and suppress the euphoria the client feels when using heroin. However, the client should not receive methadone in an emergency.

The nurse should administer bupropion, an atypical antidepressant, to a client who is trying to quit nicotine to decrease the manifestations of nicotine withdrawal and ease the client's cravings for nicotine.

The nurse should administer diazepam, a benzodiazepine, to a client who has alcohol toxicity to decrease the manifestations of alcohol withdrawal and prevent withdrawal seizures.

A nurse is teaching a client who is to start taking famotidine for peptic ulcer disease. Which of the following client statements should the nurse identify as understanding of the teaching?

A. "I will stop taking famotidine when my stomach pain is gone."

B. "I will take famotidine anytime my stomach hurts."

C. "I know smoking makes famotidine less effective."

D. "I know that famotidine will turn my stools black."

C. "I know smoking makes famotidine less effective."

Rationale:

The nurse should instruct the client that smoking decreases the effectiveness of famotidine by exacerbating the ulcer manifestations.

A nurse is assessing a client who is taking tamoxifen to treat breast cancer. Which of the following findings is the priority for nurse to report to the provider?

A. Hot flashes

B. Gastrointestinal irritation

C. Vaginal dryness

D. Leg tenderness

D. Leg tenderness

Rationale:

The greatest risk to this client is the development of a thromboembolism, which is an adverse effect of tamoxifen. The nurse should also monitor the client for other manifestations of a thromboembolism, including leg tenderness, redness, swelling, and shortness of breath.

The client is at risk for hot flashes as an adverse effect of tamoxifen. However, another finding is the priority to report to the provider. The nurse should encourage the client to avoid caffeine and spicy foods to prevent hot flashes.

The client is at risk for gastrointestinal irritation (GI) as an adverse effect of tamoxifen. However, another finding is the priority to report to the provider. The nurse should administer the medication with food or fluids to reduce GI irritation.

The client is at risk for vaginal dryness as an adverse effect of tamoxifen. However, another finding is the priority to report to the provider. The nurse should encourage the client to use vaginal moisturizers if dryness occurs.

A nurse is preparing to administer a new prescription of amoxicillin/clavulanic to a client. The client tells the nurse that they are allergic to penicillin. Which of the following actions should the nurse take first?

A. Update the client's medical record.

B. Notify the provider.

C. Withhold the medication.

D. Inform the pharmacist of the client's allergy to penicillin.

C. Withhold the medication.

Rationale:

When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority action is to withhold the medication to prevent injury to the client.

It is important to update the client's medical record to have complete information available. However, the nurse should take another action first.

It is important to notify the provider because the client will need a new prescription. However, the nurse should take another action first.

It is important to inform the pharmacist of the allergy to promote continuity of care. However, the nurse should take another action first.

A nurse is administering baclofen to a client who has a spinal cord injury. Which of the following findings should the nurse document as a therapeutic outcome?

A. Increase in seizure threshold

B. Decrease in flexor and extensor spasticity

C. Increase in cognitive function

D. Decrease in paralysis of the extremities

B. Decrease in flexor and extensor spasticity

Rationale:

A client who has a spinal cord injury and takes baclofen can experience a decrease in the frequency and severity of muscle spasms and in flexor and extensor spasticity.

A client who has a seizure disorder and takes baclofen can have a decrease in the seizure threshold, which can result in seizure activity.

A client who takes baclofen can experience the adverse effect of memory impairment and a decrease in cognitive function.

A client who takes baclofen can experience the adverse effect of inhibited reflexes at the spinal level; however, this medication does not decrease the effects of paralysis.

A nurse is planning discharge teaching for a client who has a prescription for furosemide. Which of the following statements should the nurse plan to include in the teaching?

A. "This medication increases your risk for hypertension."

B. "Avoid potassium-rich foods in your diet."

C. "Take each dose of medication in the evening before bed."

D. "Drink a glass of milk with each dose of medication."

D. "Drink a glass of milk with each dose of medication."

Rationale:

The client should take furosemide with food or milk to reduce gastric irritation.

The client who takes furosemide has an increased risk of hypotension due to fluid loss from the diuretic effect of the medication.

The client who takes furosemide has an increased risk for potassium loss because of the diuretic effect of the medication that causes excretion of potassium through the kidneys. The client should increase their intake of potassium-rich foods.

The client should take each dose of medication in the morning to avoid sleep disturbances from nocturia.

A nurse is preparing to administer ciprofloxacin 15 mg/kg PO every 12 ht to a child who weighs 20kg. How many mg should the nurse administer per dose?

300mg

Rationale:

Step 1: What is the unit of measurement the nurse should calculate? kg

Step 2: Set up an equation and solve for X.

2.2 lbClient's weight in lb = 1 kgX kg

2.2 lb44 lb = 1 kgX kg

X = 20

Step 3: What is the unit of measurement the nurse should calculate? mg

Step 4: Set up an equation and solve for X.

X=Dose per kg x client's weight in kg

X mg = 15 mg x 20

X mg = 300 mg

Step 5: Round if necessary.

Step 6: Determine whether the amount to administer makes sense. If the prescription reads 15 mg/kg every 12 hr and the child weighs 20 kg, it makes sense to give 300 mg/dose every 12 hr.

A nurse is providing discharge instructions to a client who has heart failure and new prescription for captopril. Which of the following client statements indicates an understanding of the teaching?

A. "I should take the medication with food."

B. "I should take naproxen if I develop joint pain."

C. "I should tell my provider if I develop a sore throat."

D. "I should expect the medication to cause my urine to look orange."

C. "I should tell my provider if I develop a sore throat."

Rationale:

The client should report a sore throat to the provider because this can indicate neutropenia, a serious adverse effect of captopril. Neutropenia can be reversed if it is identified early and the medication is promptly discontinued.

The client should take captopril on an empty stomach because food reduces absorption of the medication. The nurse should instruct the client to take the medication 1 hr before or 2 hr after a meal.

Naproxen and other NSAIDs can interact with captopril, which can decrease the effect of the antihypertensive and increase the risk of kidney dysfunction.

Captopril affects the urinary system by causing dysuria, urinary frequency, and changes in the normal amount of urine. However, captopril does not affect the color of the urine.

A nurse is caring for a client who has acute acetaminophen toxicity. Which of the following medications should the nurse anticipate administering?

A. Vitamin K

B. Physostigmine

C. Benztropine

D. Acetylcysteine

D. Acetylcysteine

Rationale:

Acetylcysteine is a specific antidote for acetaminophen toxicity. It can prevent severe injury when given orally or by IV infusion within 8 to 10 hr.

Benztropine is an anticholinergic medication used to treat adverse effects of Parkinson's disease by reducing rigidity and tremors.

Physostigmine is an effective antidote for antimuscarinic poisoning from medications such as atropine, scopolamine, some antihistamines, phenothiazines, and tricyclic antidepressants. It has no effect on acetaminophen toxicity.

Vitamin K is used to treat increased warfarin serum levels, indicated by elevated levels of PT/INR.

A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV over 8 hr to a client. The drop factor of the manual IV tubing is 15 gtt/mL. How many gtt/min should the nurse set the manual IV infusion to deliver?

31 gtt/min

Rationale:

Follow these steps to calculate the infusion rate using the Ratio and Proportion or Desired Over Have method of calculation:

Step 1: What is the unit of measurement the nurse should calculate? gtt/min

Step 2: What is the volume the nurse should infuse? 1 L= 1,000 mL

Step 3: What is the total infusion time? 8 hr

Step 4: Should the nurse convert the units of measurement? Yes (min does not equal hr)

1 hr8 hr = 60 minX min

X min = 480 min

Step 5: Set up an equation and solve for X.

1,000 mL15 gttX gtt/min = × 480 min1 mL

X gtt/min = 31.25 gtt/min

Step 6: Round if necessary. 31.25 = 31

Step 7: Determine whether the amount to administer makes sense. If the prescription reads 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr with a drop factor of 15 gtt/min, it makes sense to administer 31 gtt/min. The nurse should set the manual IV infusion to deliver 0.9% sodium chloride IV at 31 gtt/min.

A nurse is assessing a client's vital signs prior to the administration of PO digoxing. The client's BP is 144/86 mm HG. heart rate is 55/min, and respiratory rate is 20/min. The nurse should withhold the medication and contact the provider for which of the following findings?

A. Diastolic BP

B. Systolic BP

C. Heart rate

D. Respiratory rate

C. Heart rate

Rationale:

Digoxin slows the conduction rate through the SA and AV nodes, thereby decreasing the heart rate. The nurse should withhold the medication and notify the provider for a heart rate of 55/min because this is an early indication of digoxin toxicity.

Digoxin increases cardiac output and reduces the heart rate. A diastolic BP of 86 mm Hg is not a cause for withholding the medication and contacting the provider.

Digoxin increases cardiac output and reduces the heart rate. A systolic BP of 140 mm Hg is not a cause for withholding the medication and contacting the provider.

Digoxin increases cardiac output and reduces heart rate. A respiratory rate of 20/min is not a cause for withholding the medication and contacting the provider.

A nurse is providing teaching to a client who has multiple sclerosis and new prescription for methylprednisolone. Which of the following instructions should the nurse include?

A. Blood glucose levels will be monitored during therapy.

B. Avoid contact with people who have known infections.

C. Take the medication 1 hr before breakfast.

D. Decrease dietary intake of foods containing potassium.

E. Grapefruit juice can increase the effects of the medication.

A. Blood glucose levels will be monitored during therapy.

B. Avoid contact with people who have known infections.

E. Grapefruit juice can increase the effects of the medication.

Rationale:

Blood glucose levels will be monitored during therapy is correct. The nurse should monitor the client for hyperglycemia while providing methylprednisolone to the client. Glucocorticoids, such as methylprednisolone, increase serum glucose levels and can require management with insulin or antihyperglycemics.Avoid contact with people who have known infections is correct. The nurse should instruct the client to avoid exposure to infectious agents, such as contact with those who have active infections or illnesses. Glucocorticoids, such as methylprednisolone, depress the immune system, placing the client at an increased risk for developing an infection.Take the medication 1 hr before breakfast is incorrect. The nurse should instruct the client to take the medication with food or milk to decrease gastrointestinal upset.Decrease dietary intake of foods containing potassium is incorrect. The nurse should instruct the client to increase dietary intake of potassium-rich foods while taking this medication. Glucocorticoids, such as methylprednisolone, deplete potassium in the body, which manifests as hypokalemia.Grapefruit juice can increase the effects of the medication is correct. The nurse should instruct the client that grapefruit and grapefruit juice can increase the level of methylprednisolone in the body.

A nurse is caring for a client who has hypocalcemia and is receiving calcium citrate. The nurse should identify that which of the following findings indicates a therapeutic response to the medication?

A. Positive Chvostek's sign

B. Client report of decreased paresthesia

C. Client report of increased thirst

D. Increase in urinary output

B. Client report of decreased paresthesia

Rationale:

Paresthesia is a manifestation of hypocalcemia. A client report of a decrease in paresthesia is an indication of a therapeutic response to calcium citrate. The nurse should also monitor for a decrease in other manifestations of hypocalcemia, including muscle twitching and cardiac dysrhythmias.

A positive Chvostek's sign is a manifestation of hypocalcemia and does not indicate a therapeutic response to calcium citrate.

An increase in thirst is a manifestation of hypercalcemia and can be an indication of calcium toxicity. The nurse should monitor the client for other manifestations of hypercalcemia, such as nausea, vomiting, or anorexia.

Calcium citrate is a calcium salt used in the treatment of hypocalcemia. An increase in urinary output does not indicate a therapeutic response to this medication.

A nurse is providing teaching to a client who has a prescription for erotamine sublingial to treat migraine headaches. Which of the following information should the nurse include in the instructions?

A. "Take one tablet three times a day before meals."

B. "Take one tablet every 15 minutes until migraine subsides."

C. "Take up to eight tablets as needed within a 24-hour period."

D. "Take one tablet at onset of migraine."

D. "Take one tablet at onset of migraine."

Rationale:

The client should take one tablet immediately after the onset of aura or headache.

A nurse is providing teaching to a client about the use of ethinyl estradiol/ norelgestromin. Which of the following statements by the client indicates an understanding of the teaching?

A. "I will apply the patch once a week for 2 weeks."

B. "I will leave the existing patch on for 4 hours after applying the new patch."

C. "I will fold the sticky sides of the old patch together before disposing it."

D. "I will apply the patch within 14 days of menses."

C. "I will fold the sticky sides of the old patch together before disposing it."

Rationale:

The client should fold the sticky sides of the old patch together and then place it in a childproof container to ensure safe disposal of the patch.

The client should apply the patch once a week for 3 weeks and then go without the patch for 1 week to promote menstruation.

The client should remove and dispose the old patch before applying a new patch to prevent toxicity by combining the remaining medication on the old patch with the medication on the new patch.

The client should apply the patch within 7 days of menses to prevent ovulation and the need for another contraceptive method.

A nurse is caring for a client in an outpatient clinic.

History and Physical

11 months ago:

Client reports bilateral knee pain for many years for which they have taken ibuprofen 800 mg up to four times per day as needed for the last year. It is no longer effective for pain. Reports pain today as 7 on a 0 to 10 scale.

6 months ago:

Client reports 5 on a 0 to 10 scale for right upper quadrant abdominal pain and dyspepsia for the last 3 months. Appetite decreased due to occasional nausea.

Abdomen:

Soft, slightly distended, nontender, bowel sounds present in all four quadrants

Esophagogastroduodenoscopy (EGD) prescribed.

Today:

Client reports no dyspepsia, nausea, or abdominal pain with continued use of omeprazole. Knee pain is reported as 2 on a 0 to 10 scale with continued use of naproxen.

Diagnostic Results

5 months ago:

Esophagogastroduodenoscopy (EGD) reveals peptic ulcer in proximal duodenum.

Provider Prescript

The nurse is reviewing the client's medical record, which of the following is the client at risk for developing

due to

.Upon analyzing cues, the nurse should identify that the client is at risk for developing hypomagnesemia due to long-term use of omeprazole and should monitor magnesium laboratory values and observe for manifestations including tremors, seizures, and muscle cramps.

A nurse in an outpatient clinic is caring for a client.

Vital Signs

Initial visit:

Temperature 36.5° C (97.7° F)

Heart rate 72/min

Blood pressure 118/74 mm Hg

Respiratory rate 15/min

SpO2 99% on room air

Follow-up visit:

Temperature 36.7° C (98.1° F)

Heart rate 92/min

Blood pressure 132/88 mm Hg

Respiratory rate 18/min

SpO2 98% on room air

Nurses' NotesInitial visit:

Client presents for evaluation of an increase in headaches over past several months. Client reports headaches occur three to six times per month and typically last a few hours to three days. Headaches are often accompanied by neck pain and nausea. Client reports working full-time at a desk job and is using a computer all day. States last eye exam was three months ago.

Follow-up visit:

Client presents with report of a severe headache for the past four days that is unrelieved by rest and over the counter analgesics. The client states that they have be

The nurse is planning teaching about the client's new medication. Which of the following information should the nurse include? Select all that apply.

When generating solutions and planning teaching about sumatriptan, an abortive medication for migraine, the nurse should inform the client that a feeling of pressure in the chest or arm heaviness is an expected adverse effect. Sumatriptan can also cause fatigue. Oral sumatriptan begins to alleviate migraine pain within one hour and a second dose can be taken at least two hours later if manifestations persist.

A nurse is monitoring a client after administering their prescribed medications.

Nurses' Notes

2000:

Client is alert to person, place, time, and situation. Client reports headache and occasional anxiety.

Client reports nausea. Abdomen soft and rounded, non-distended. Bowel sounds are normoactive in all 4 quadrants.

Bladder non-distended; continent. Urine output of 25 mL/hr.

Skin cool, dry and intact.

Small pinpoint petechiae is present on bilateral extremities.

Vital Signs

1600:

Temperature 37.7° C (99.9° F)

Heart rate 100/min

Respiratory rate 20/min

Blood pressure 134/64 mm Hg

Oxygen Saturation 96% on room air

2000:

Temperature 38.4° C (101.2° F)

Heart rate 106/min

Respiratory rate 20/min

Blood pressure 140/64 mm Hg

Oxygen Saturation 97% on room air

Medication Administration Record

Enoxaparin 40 mg Subcutaneous daily

When analyzing cues, the nurse should identify that the client's report of headache, nausea, and small pinpoint petechiae is present on bilateral extremities are indications of a potential adverse reaction to enoxaparin. Low molecular weight heparins such as enoxaparin are anticoagulants that are used to prevent thrombus formation. Other findings of an adverse reaction include, peripheral edema, insomnia, hematuria, pruritis, and alopecia.