Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?
A. Diarrhea
A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.
B. Dry mouth
B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.
C. Photophobia
C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.
D. Bruising
D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.
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Full Explanation
- A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.
- B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.
- C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.
- D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.
Similar Questions
A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?
A. Tinnitus
A is incorrect because tinnitus, or ringing in the ears, is not an adverse effect of captopril, but rather a symptom of other conditions such as ear infection, noise exposure, or medication toxicity.
B. Cough
B is correct because cough is a serious adverse effect of captopril, which is an angiotensinconverting enzyme (ACE) inhibitor that can cause angioedema, or swelling of the airways.
C. Polyuria
C is incorrect because polyuria, or excessive urination, is not an adverse effect of captopril, but rather a symptom of other conditions such as diabetes mellitus, diabetes insipidus, or diuretic use.
D. Blurred vision
D is incorrect because blurred vision is not an adverse effect of captopril, but rather a symptom of other conditions such as eye strain, refractive error, or cataract.
Full Explanation
- A is incorrect because tinnitus, or ringing in the ears, is not an adverse effect of captopril, but rather a symptom of other conditions such as ear infection, noise exposure, or medication toxicity.
- B is correct because cough is a serious adverse effect of captopril, which is an angiotensinconverting enzyme (ACE) inhibitor that can cause angioedema, or swelling of the airways.
- C is incorrect because polyuria, or excessive urination, is not an adverse effect of captopril, but rather a symptom of other conditions such as diabetes mellitus, diabetes insipidus, or diuretic use.
- D is incorrect because blurred vision is not an adverse effect of captopril, but rather a symptom of other conditions such as eye strain, refractive error, or cataract.
A nurse is planning care for a client who is receiving chemotherapy and has neutropenia.
Which of the following interventions should the nurse include in the plan?
A. Avoid including raw fruits in the client's diet.
The nurse should discourage raw fruits due to risk of infection.
B. Restrict visits from young children to 2 hr per day.
There is no standard recommendation against exposure to young children.
C. Measure the client's temperature once per shift.
The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated, because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.
D. Use disposable gloves from a box outside the client's room.
The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.
Full Explanation
- A. The nurse should discourage raw fruits due to risk of infection.
- B. There is no standard recommendation against exposure to young children.
- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.
- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.
A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?
A. The frequency in which the client presses the call button
The frequency in which the client presses the call button:While this could be relevant to assess the client's overall well-being or potential anxiety, it's not as crucial as pain management in this specific scenario.
B. The client's most recent ventilator settings
The client's most recent ventilator settings:Since the client is already weaned from ventilation, this information is no longer pertinent.
C. The time of the client's last dose of pain medication
The time of the client's last dose of pain medication:Pain management is paramount after a pneumonectomy. Knowing the timing of the last dose allows the receiving nurse to assess the need for further medication and potential for breakthrough pain management. Additionally, it provides a baseline for monitoring pain trends and potential complications related to pain, such as decreased mobility or respiratory compromise.
D. The last time the provider evaluated the client
The last time the provider evaluated the client:While provider updates are important, especially after major procedures like a pneumonectomy, knowing the exact timing isn't as critical as pain management, especially considering the potential for increased pain after surgery and weaning from ventilation.
Full Explanation
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Out of the provided options, the most important information for the nurse to include in the change-of-shift report is:
c. The time of the client's last dose of pain medication
Here's why:
- a. The frequency in which the client presses the call button: While this could be relevant to assess the client's overall well-being or potential anxiety, it's not as crucial as pain management in this specific scenario.
- b. The client's most recent ventilator settings: Since the client is already weaned from ventilation, this information is no longer pertinent.
- d. The last time the provider evaluated the client: While provider updates are important, especially after major procedures like a pneumonectomy, knowing the exact timing isn't as critical as pain management, especially considering the potential for increased pain after surgery and weaning from ventilation.
- c. The time of the client's last dose of pain medication: Pain management is paramount after a pneumonectomy. Knowing the timing of the last dose allows the receiving nurse to assess the need for further medication and potential for breakthrough pain management. Additionally, it provides a baseline for monitoring pain trends and potential complications related to pain, such as decreased mobility or respiratory compromise.
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Therefore, while all the information listed could be relevant at some point, knowing the time of the last pain medication dose is the most crucial for immediate patient care and should be prioritized in the change-of-shift report for a post-pneumonectomy client transitioning from ICU to the medical floor.