Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a prescription for amoxicillin. Which of the following findings indicates the client is experiencing an allergic reaction?
A. Laryngeal edema.
Laryngeal edema is a sign of a severe allergic reaction to amoxicillin that can cause difficulty breathing and may be life threatening. The nurse should stop the medication and call for emergency assistance.
B. Nausea.
Choice B is wrong because nausea is a common side effect of amoxicillin, not an allergic reaction.
C. Insomnia.
Choice C is wrong because insomnia is not related to amoxicillin use.
D. Cardiac dysrhythmia.
Choice D is wrong because cardiac dysrhythmia is not a typical symptom of an allergic reaction to amoxicillin. It may be caused by other factors, such as underlying heart disease or electrolyte imbalance.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Pharmacology 2019 Proctored Exam. Take the full exam now
Full Explanation
Laryngeal edema is a sign of a severe allergic reaction to amoxicillin that can cause difficulty breathing and may be life threatening.
The nurse should stop the medication and call for emergency assistance. Choice B is wrong because nausea is a common side effect of amoxicillin, not an allergic reaction.
Choice C is wrong because insomnia is not related to amoxicillin use. Choice D is wrong because cardiac dysrhythmia is not a typical symptom of an allergic reaction to amoxicillin.
It may be caused by other factors, such as underlying heart disease or electrolyte imbalance.
Similar Questions
A nurse is preparing to administer enoxaparin to a client.
Which of the following actions should the nurse take?
A. Expel the air bubble from the syringe prior to injection.
The air bubble should not be expelled from the syringe before administering enoxaparin. The air bubble is included to ensure that the entire dose is administered and to help prevent leakage of the medication into the subcutaneous tissue, which can reduce bruising.
B. Apply firm pressure to the injection site following administration.
After administering enoxaparin, applying firm pressure (but not massaging) to the injection site helps minimize bruising and bleeding. It's important not to massage the site as this can increase the risk of bleeding.
C. Insert the syringe needle halfway into the client’s skin.
The needle should be inserted fully into the subcutaneous tissue at a 90-degree angle (or at a 45-degree angle if the client has little subcutaneous tissue). Inserting the needle halfway may result in improper administration.
D. Administer the medication into the client’s muscles.
Enoxaparin is a low-molecular-weight heparin that should be administered subcutaneously, not intramuscularly. Administering it intramuscularly could increase the risk of bleeding and is not the appropriate route for this medication.
Full Explanation
Choice A rationale:
The air bubble should not be expelled from the syringe before administering enoxaparin. The air bubble is included to ensure that the entire dose is administered and to help prevent leakage of the medication into the subcutaneous tissue, which can reduce bruising.
Choice B rationale:
After administering enoxaparin, applying firm pressure (but not massaging) to the injection site helps minimize bruising and bleeding. It's important not to massage the site as this can increase the risk of bleeding.
Choice C rationale:
The needle should be inserted fully into the subcutaneous tissue at a 90-degree angle (or at a 45-degree angle if the client has little subcutaneous tissue). Inserting the needle halfway may result in improper administration.
Choice D rationale:
Enoxaparin is a low-molecular-weight heparin that should be administered subcutaneously, not intramuscularly. Administering it intramuscularly could increase the risk of bleeding and is not the appropriate route for this medication.
A nurse is caring for a client who has breast cancer and reports pain 1 hr after administration of prescribed morphine 10 mg IV.
Which of the following medications should the nurse expect to administer?
A. Fentanyl transmucosal.
This is because fentanyl transmucosal is a fast-acting opioid that can be used for breakthrough pain in patients who are already receiving opioids for chronic pain. Breakthrough pain is a sudden and severe increase in pain that occurs despite the use of regular pain medication. Fentanyl transmucosal has a rapid onset of action (1-3 minutes) and a short duration of effect (1-2 hours), which makes it suitable for treating episodic pain.
B. Lidocaine patch.
Choice B. Lidocaine patch is wrong because lidocaine patch is a topical anesthetic that can be used for localized neuropathic pain, but not for acute or severe pain.
C. Morphine tablet.
Choice C. Morphine tablet is wrong because morphine tablet is a long-acting opioid that can be used for chronic pain, but not for breakthrough pain. Morphine tablet has a slow onset of action (30-60 minutes) and a long duration of effect (3-4 hours), which makes it unsuitable for treating episodic pain.
D. Naloxone IV.
Choice D. Naloxone IV is wrong because naloxone IV is an opioid antagonist that can reverse the effects of opioids, but not relieve pain. Naloxone IV can cause acute withdrawal symptoms in patients who are dependent on opioids.
Full Explanation
This is because fentanyl transmucosal is a fast-acting opioid that can be used for breakthrough pain in patients who are already receiving opioids for chronic pain. Breakthrough pain is a sudden and severe increase in pain that occurs despite the use of regular pain medication. Fentanyl transmucosal has a rapid onset of action (1-3 minutes) and a short duration of effect (1-2 hours), which makes it suitable for treating episodic pain.
Choice B. Lidocaine patch is wrong because lidocaine patch is a topical anesthetic that can be used for localized neuropathic pain, but not for acute or severe pain.
Choice C. Morphine tablet is wrong because morphine tablet is a long-acting opioid that can be used for chronic pain, but not for breakthrough pain. Morphine tablet has a slow onset of action (30-60 minutes) and a long duration of effect (3-4 hours), which makes it unsuitable for treating episodic pain.
Choice D. Naloxone IV is wrong because naloxone IV is an opioid antagonist that can reverse the effects of opioids, but not relieve pain.
Naloxone IV can cause
A nurse accidentally administers the medication metformin instead of metoprolol to a client.
Which of the following actions should the nurse take?
A. Obtain the client’s HDL level.
Choice A is wrong because HDL (high-density lipoprotein) is a type of cholesterol that is not affected by metformin or metoprolol.
B. Monitor the client’s thyroid function levels.
Choice B is wrong because thyroid function levels are not affected by metformin or metoprolol.
C. Collect the client’s uric acid level.
Choice C is wrong because uric acid level is not affected by metformin or metoprolol. Uric acid is a waste product that can cause gout if it accumulates in the joints. Normal ranges for blood glucose are 70 to 130 mg/dL before meals and less than 180 mg/dL two hours after meals. Normal ranges for HDL are 40 to 60 mg/dL for men and 50 to 60 mg/dL for women. Normal ranges for thyroid function levels vary depending on the specific test, but generally they are between 0.4 and 4.0 mIU/L for TSH (thyroid-stimulating hormone), 4.5 to 11.2 mcg/dL for T4 (thyroxine), and 80 to 180 ng/dL for T3 (triiodothyronine). Normal ranges for uric acid are 3.4 to 7.0 mg/dL for men and 2.4 to 6.0 mg/dL for women.
D. Check the client’s glucose level.
Metformin is a medication used to lower blood glucose levels in people with type 2 diabetes. Metoprolol is a beta-blocker used to treat high blood pressure and heart problems. If the nurse accidentally gives metformin instead of metoprolol, the client may experience hypoglycemia (low blood sugar), which can cause symptoms such as sweating, shakiness, confusion, and loss of consciousness. Therefore, the nurse should check the client’s glucose level and treat hypoglycemia if needed.
Full Explanation
Metformin is a medication used to lower blood glucose levels in people with type 2 diabetes. Metoprolol is a beta-blocker used to treat high blood pressure and heart problems. If the nurse accidentally gives metformin instead of metoprolol, the client may experience hypoglycemia (low blood sugar), which can cause symptoms such as sweating, shakiness, confusion, and loss of consciousness. Therefore, the nurse should check the client’s glucose level and treat hypoglycemia if needed.
Choice A is wrong because HDL (high-density lipoprotein) is a type of cholesterol that is not affected by metformin or metoprolol.
Choice B is wrong because thyroid function levels are not affected by metformin or metoprolol.
Choice C is wrong because uric acid level is not affected by metformin or metoprolol.
Uric acid is a waste product that can cause gout if it accumulates in the joints. Normal ranges for blood glucose are 70 to 130 mg/dL before meals and less than 180 mg/dL two hours after meals.
Normal ranges for HDL are 40 to 60 mg/dL for men and 50 to 60 mg/dL for women.
Normal ranges for thyroid function levels vary depending on the specific test, but generally they are between 0.4 and 4.0 mIU/L for TSH (thyroid-stimulating hormone), 4.5 to 11.2 mcg/dL for T4 (thyroxine), and 80 to 180 ng/dL for T3 (triiodothyronine).
Normal ranges for uric acid are 3.4 to 7.0 mg/dL for men and 2.4 to 6.0 mg/dL for women.