Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has chronic hepatitis B infection and is taking lamivudine (Epivir).
The nurse should monitor the client for which of the following adverse effects?
A. Pancreatitis
Pancreatitis is not a common side effect of lamivudine. Pancreatitis is an inflammation of the pancreas that can cause severe abdominal pain, nausea, vomiting, and fever.Pancreatitis is more likely to occur with other NRTIs such as didanosine (Videx) or stavudine (Zerit).
B. Lactic acidosis
Lamivudine (Epivir) is a nucleoside reverse transcriptase inhibitor (NRTI) used to treat chronic hepatitis B infection and HIV infection. One of the rare but serious adverse effects of lamivudine is lactic acidosis, which is a condition where the blood becomes too acidic due to the accumulation of lactate.Lactic acidosis can cause symptoms such as nausea, vomiting, abdominal pain, muscle weakness, rapid breathing, and low blood pressure.
C. Hypothyroidism
Hypothyroidism is not a common side effect of lamivudine. Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones, which regulate the metabolism and energy levels of the body. Hypothyroidism can cause symptoms such as fatigue, weight gain, cold intolerance, dry skin, hair loss, and depression. Hypothyroidism is more likely to occur with other drugs that interfere with thyroid function such as amiodarone (Cordarone) or lithium
D. Nephrotoxicity
N/A
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Full Explanation
The correct answer is choice B. Lactic acidosis.
Lamivudine (Epivir) is a nucleoside reverse transcriptase inhibitor (NRTI) used to treat chronic hepatitis B infection and HIV infection.
One of the rare but serious adverse effects of lamivudine is lactic acidosis, which is a condition where the blood becomes too acidic due to the accumulation of lactate. Lactic acidosis can cause symptoms such as nausea, vomiting, abdominal pain, muscle weakness, rapid breathing, and low blood pressure.
Choice A is wrong because pancreatitis is not a common side effect of lamivudine.
Pancreatitis is an inflammation of the pancreas that can cause severe abdominal pain, nausea, vomiting, and fever. Pancreatitis is more likely to occur with other NRTIs such as didanosine (Videx) or stavudine (Zerit).
Choice C is wrong because hypothyroidism is not a common side effect of lamivudine.
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones, which regulate the metabolism and energy levels of the body.
Hypothyroidism can cause symptoms such as fatigue, weight gain, cold intolerance, dry skin, hair loss, and depression.
Hypothyroidism is more likely to occur with other drugs that interfere with thyroid function such as amiodarone (Cordarone) or lithium
Similar Questions
A nurse is educating a new mother about umbilical cord care and how to prevent omphalitis, sepsis, and tetanus.
Which of the following statements by the mother indicates an understanding of the teaching?
A. “I should wash my hands before and after handling the cord stump.”
Washing hands before and after handling the cord stump can prevent the transmission of bacteria that can cause omphalitis, sepsis, and tetanus.
B. “I should apply petroleum jelly or ointment to the cord stump after each diaper change.”
Applying petroleum jelly or ointment to the cord stump can delay its drying and increase the risk of infection.
C. “I should use a cotton swab dipped in hydrogen peroxide to clean around the base of the cord stump.”
Using hydrogen peroxide to clean the cord stump can damage the healthy tissue and delay healing.
D. “I should fold down the top of the diaper below the cord stump until it falls off.”
Folding down the diaper below the cord stump can expose it to urine and feces, which can contaminate it and cause infection.
Full Explanation
The correct answer is choice A. Washing hands before and after handling the cord stump can prevent the transmission of bacteria that can cause omphalitis, sepsis, and tetanus.
Choice B is wrong because applying petroleum jelly or ointment to the cord stump can delay its drying and increase the risk of infection.
Choice C is wrong because using hydrogen peroxide to clean the cord stump can damage the healthy tissue and delay healing.
Choice D is wrong because folding down the diaper below the cord stump can expose it to urine and feces, which can contaminate it and cause infection.
The normal range for umbilical cord separation is 5 to 15 days after birth.
A postpartum nurse instructs a new mother in how to bathe her newborn.
Which statement by the mother indicates a need for further instruction?
A. “I should use a clean cloth and warm water to wash around the umbilical cord.”
It is correct to use a clean cloth and warm water to wash around the umbilical cord.This helps prevent infection and promotes drying of the cord stump.
B. “I should bathe him before a feeding so he won’t spit up.”
This statement indicates a need for further instruction because it is not advisable to bathe a newborn infant before a feeding, as this may cause hypoglycemia or cold stress.The mother should bathe the infant after a feeding or between feedings when the infant is alert and comfortable.
C. “I should avoid getting water in his ears or eyes.”
It is correct to avoid getting water in the infant’s ears or eyes.This helps prevent ear infections and eye irritation.
D. “I should avoid getting water in his ears or eyes.”
It is correct to dry the infant thoroughly and dress him warmly after bathing. This helps prevent heat loss
Full Explanation
The correct answer is choice B. “I should bathe him before a feeding so he won’t spit up.” This statement indicates a need for further instruction because it is not advisable to bathe a newborn infant before a feeding, as this may cause hypoglycemia or cold stress. The mother should bathe the infant after a feeding or between feedings when the infant is alert and comfortable.
Choice A is wrong because it is correct to use a clean cloth and warm water to wash around the umbilical cord. This helps prevent infection and promotes drying of the cord stump.
Choice C is wrong because it is correct to avoid getting water in the infant’s ears or eyes. This helps prevent ear infections and eye irritation.
Choice D is wrong because it is correct to dry the infant thoroughly and dress him warmly after bathing.
This helps prevent heat loss
The nurse is caring for a newborn who was circumcised using a Gomco clamp 12 hours ago and notes that there is a small amount of blood on his diaper where his penis rests against it.
The most appropriate nursing action would be to:
A. Apply gentle pressure to stop bleeding
Applying gentle pressure to stop bleeding is not necessary and may cause more trauma to the wound.
B. Change his diaper more frequently
Changing the diaper more frequently may also disturb the healing process and increase the risk of infection.
C. Document this as a normal finding
Document this as a normal finding.According to the American Academy of Family Physicians, bleeding from the dorsal slit after circumcision using a Gomco clamp is usually minimal and will stop once the clamp is in place. Therefore, a small amount of blood on the diaper 12 hours after the procedure is not a cause for concern and does not require any intervention.
D. Notify his physician
Notifying the physician is not indicated unless there is excessive or persistent bleeding, signs of infection, or other complications.
Full Explanation
The correct answer is choice C. Document this as a normal finding. According to the American Academy of Family Physicians, bleeding from the dorsal slit after circumcision using a Gomco clamp is usually minimal and will stop once the clamp is in place.
Therefore, a small amount of blood on the diaper 12 hours after the procedure is not a cause for concern and does not require any intervention.
Choice A is wrong because applying gentle pressure to stop bleeding is not necessary and may cause more trauma to the wound.
Choice B is wrong because changing the diaper more frequently may also disturb the healing process and increase the risk of infection. Choice D is wrong because notifying the physician is not indicated unless there is excessive or persistent bleeding, signs of infection, or other complications.