Question

A nurse is caring for a client who is taking oral erythromycin. Which of the following statements by the nurse indicates the client is experiencing a common adverse effect of this medication?

Answer 1

Correct Answers:

"The client had a small amount of yellow emesis."

Rationale :

🔶 Erythromycin, a macrolide antibiotic, commonly causes gastrointestinal upset, including nausea, vomiting, abdominal cramping, and diarrhea, due to its prokinetic effect on GI motility.

🔶 The report of yellow emesis indicates vomiting, which aligns with this known adverse effect and is one of the most frequently reported issues with erythromycin therapy.

🔶 This effect occurs even at therapeutic doses and is dose-dependent, sometimes leading to poor adherence to the medication if not managed properly.

🔶 Monitoring for dehydration and advising the client to take the medication with food (if not contraindicated) can help reduce GI distress.

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Answer 2

Correct Answers:

Administer the regular dose of lithium.

Rationale :

💠 A lithium level of 1.2 mEq/L is within the therapeutic range for maintenance therapy in clients with bipolar disorder. The therapeutic range is typically 0.6–1.2 mEq/L, though some providers may allow up to 1.5 mEq/L in acute manic episodes.

💠 Since the level is safe and not indicative of toxicity, the nurse should continue administering the prescribed dose and monitor for symptoms of toxicity (e.g., tremors, confusion, nausea).

💠 No immediate intervention is required unless the client develops clinical signs of lithium toxicity, in which case reassessment and lab confirmation are needed.

💠 Routine monitoring is essential because lithium has a narrow therapeutic index, meaning small changes in dose or renal function can lead to toxicity.

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Answer 3

Correct Answers:

Lorazepam

Rationale :

🔷 Lorazepam, a benzodiazepine, is the medication of choice for managing alcohol withdrawal delirium because it helps reduce the risk of seizures and agitation by enhancing GABA activity, the main inhibitory neurotransmitter in the CNS.

🔷 It provides sedation, muscle relaxation, and anticonvulsant properties, which are essential in stabilizing vital signs and preventing delirium tremens (DTs).

🔷 Benzodiazepines like lorazepam also minimize the risk of progression to more severe withdrawal complications such as hallucinations, hypertension, and seizures.

🔷 Lorazepam is preferred in clients with hepatic impairment because it has no active metabolites and is safer for older adults or those with liver disease.

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Answer 4

Correct Answers:

Dorsal recumbent

Rationale :

🔶 The dorsal recumbent position is ideal for administering vaginal medications because it allows maximum access to the vaginal canal while ensuring the client is comfortable and well-supported.

🔶 In this position, the client lies on her back with knees bent and feet flat, which facilitates proper insertion of the cream applicator and promotes medication distribution.

🔶 This position also helps prevent leakage of the cream and allows the client to remain relaxed during the procedure.

🔶 It is a standard position used for gynecological exams and vaginal treatments due to its effectiveness and ease of use in both clinical and home settings.

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Answer 5

Correct Answers:

Avocadoes

Rationale :

💥 Avocados, especially when overripe, are high in tyramine, a naturally occurring compound that can cause hypertensive crisis when combined with MAOIs due to impaired breakdown of tyramine.

💥 Clients taking MAOIs must follow a tyramine-restricted diet to prevent severe vasoconstriction and elevated blood pressure, which can result from tyramine accumulation.

💥 Other tyramine-rich foods include aged cheeses, cured meats, fermented products, and certain fruits like overripe bananas and avocados.

💥 Foods such as 2% milk, apples, and celery sticks are low in tyramine and considered safe for clients on MAOIs.

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Answer 6

Correct Answers:

Sedation

Rationale :

💤 Alprazolam, a benzodiazepine, enhances the effects of gamma-aminobutyric acid (GABA) in the brain, leading to central nervous system (CNS) depression.

💤 One of the most common adverse effects is sedation, which may present as drowsiness, fatigue, or impaired coordination, especially when therapy is initiated or the dose is increased.

💤 Sedation can impair safety, particularly in older adults, increasing the risk of falls and confusion, and should be closely monitored.

💤 Clients should be taught to avoid driving or operating heavy machinery until they understand how the medication affects them.

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Answer 7

Correct Answers:

Hydrops fetalis

Rationale :

🔴 Hydrops fetalis is a severe, life-threatening complication of Rh incompatibility where maternal Rh-negative antibodies attack fetal Rh-positive red blood cells, leading to massive hemolysis.

🔴 The destruction of fetal erythrocytes causes severe anemia, hypoxia, and cardiac failure, resulting in generalized edema, pleural effusion, and ascites—hallmarks of hydrops fetalis.

🔴 Rho(D) immunoglobulin is given to Rh-negative mothers during and after pregnancy to prevent sensitization and the formation of antibodies against Rh-positive blood cells.

🔴 Early administration of this immunoglobulin significantly reduces the risk of alloimmunization and protects future pregnancies.

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Answer 8

Correct Answers:

Postpartum hemorrhage

Rationale :

🔷 Methylergonovine is an uterotonic agent that stimulates sustained contraction of uterine smooth muscle, promoting uterine involution and reducing bleeding after childbirth.

🔷 It is commonly used to prevent or manage postpartum hemorrhage (PPH), especially when caused by uterine atony, which is the failure of the uterus to contract effectively.

🔷 By increasing myometrial tone, it helps compress uterine blood vessels and minimize blood loss.

🔷 The nurse must monitor blood pressure closely before and after administration, as methylergonovine can cause vasoconstriction and hypertension as side effects.

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Answer 9

Correct Answers:

Thyroid enlargement

Rationale :

🔶 Lithium carbonate can interfere with thyroid hormone synthesis, leading to goiter (thyroid enlargement) and, over time, potential hypothyroidism.

🔶 Clients may develop weight gain, fatigue, and cold intolerance as signs of decreased thyroid function, so regular thyroid function tests (TSH, T3, T4) are essential during long-term therapy.

🔶 Lithium also affects iodine uptake by the thyroid gland, which contributes to enlargement and hormonal imbalance.

🔶 Monitoring for goiter or neck swelling is a key component of long-term management in clients taking lithium.

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Answer 10

Correct Answers:

Isosorbide

Rationale :

🔴 Sildenafil, a phosphodiesterase type 5 (PDE5) inhibitor, is contraindicated with nitrates like isosorbide because the combination can cause severe, potentially life-threatening hypotension.

🔴 Both medications enhance nitric oxide, which leads to profound vasodilation and a dramatic drop in blood pressure that can result in syncope, myocardial infarction, or stroke.

🔴 Clients taking isosorbide mononitrate or dinitrate for angina or heart failure must avoid sildenafil and similar agents such as tadalafil or vardenafil.

🔴 The nurse should immediately alert the provider to prevent dangerous drug interactions and reinforce client safety education regarding the use of nitrates and erectile dysfunction medications.

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QLexNursing

1 :
A nurse is caring for a client who is taking oral erythromycin. Which of the following statements by the nurse indicates the client is experiencing a common adverse effect of this medication?

2 :
A nurse is reviewing the morning laboratory report for a client who has bipolar disorder and recently started taking lithium. The client's current lithium level is 1.2 mEq/L. Which of the following actions should the nurse plan to take?

3 :
A nurse is caring for a client who begins showing signs of alcohol withdrawal delirium. Which of the following medications should the nurse administer?

4 :
A nurse is preparing to administer a vaginal cream to a client. The nurse should instruct the client to lie in which of the following positions while in bed?

5 :
A nurse is reinforcing dietary teaching for a client who is to start taking a monoamine oxidase inhibitor (MAOI). Which of the following food choices should the nurse identify as having the highest tyramine content?

6 :
A nurse is collecting data from client who has just begun therapy with alprazolam to treat anxiety. The nurse should observe the client for which of the following adverse effects of this medication?

7 :
A nurse is reinforcing teaching about Rho(D) immunoglobulin to a client who is pregnant. Which of the following findings can an Rh incompatibility cause?

8 :
A nurse is preparing to administer methylergonovine IM for a client who had a vaginal delivery earlier that day. The nurse should explain to the client that this medication will help prevent which of the following?

9 :
A nurse is reinforcing teaching with a client who takes lithium carbonate for bipolar disorder. For which of the following findings should the nurse monitor as an adverse effect of lithium carbonate?

10 :
A nurse is collecting data from a client who takes several daily medications and states that he wants to ask the provider for a prescription for sildenafil. The nurse knows that sildenafil is contraindicated due to an interaction with which of the following client's medications?

QLexNursing

1 : A nurse is caring for a client who is taking oral erythromycin. Which of the following statements by the nurse indicates the client is experiencing a common adverse effect of this medication?

2 : A nurse is reviewing the morning laboratory report for a client who has bipolar disorder and recently started taking lithium. The client's current lithium level is 1.2 mEq/L. Which of the following actions should the nurse plan to take?

3 : A nurse is caring for a client who begins showing signs of alcohol withdrawal delirium. Which of the following medications should the nurse administer?

4 : A nurse is preparing to administer a vaginal cream to a client. The nurse should instruct the client to lie in which of the following positions while in bed?

5 : A nurse is reinforcing dietary teaching for a client who is to start taking a monoamine oxidase inhibitor (MAOI). Which of the following food choices should the nurse identify as having the highest tyramine content?

6 : A nurse is collecting data from client who has just begun therapy with alprazolam to treat anxiety. The nurse should observe the client for which of the following adverse effects of this medication?

7 : A nurse is reinforcing teaching about Rho(D) immunoglobulin to a client who is pregnant. Which of the following findings can an Rh incompatibility cause?

8 : A nurse is preparing to administer methylergonovine IM for a client who had a vaginal delivery earlier that day. The nurse should explain to the client that this medication will help prevent which of the following?

9 : A nurse is reinforcing teaching with a client who takes lithium carbonate for bipolar disorder. For which of the following findings should the nurse monitor as an adverse effect of lithium carbonate?

10 : A nurse is collecting data from a client who takes several daily medications and states that he wants to ask the provider for a prescription for sildenafil. The nurse knows that sildenafil is contraindicated due to an interaction with which of the following client's medications?

1 :
A nurse is caring for a client who is taking oral erythromycin. Which of the following statements by the nurse indicates the client is experiencing a common adverse effect of this medication?

2 :
A nurse is reviewing the morning laboratory report for a client who has bipolar disorder and recently started taking lithium. The client's current lithium level is 1.2 mEq/L. Which of the following actions should the nurse plan to take?

3 :
A nurse is caring for a client who begins showing signs of alcohol withdrawal delirium. Which of the following medications should the nurse administer?

4 :
A nurse is preparing to administer a vaginal cream to a client. The nurse should instruct the client to lie in which of the following positions while in bed?

5 :
A nurse is reinforcing dietary teaching for a client who is to start taking a monoamine oxidase inhibitor (MAOI). Which of the following food choices should the nurse identify as having the highest tyramine content?

6 :
A nurse is collecting data from client who has just begun therapy with alprazolam to treat anxiety. The nurse should observe the client for which of the following adverse effects of this medication?

7 :
A nurse is reinforcing teaching about Rho(D) immunoglobulin to a client who is pregnant. Which of the following findings can an Rh incompatibility cause?

8 :
A nurse is preparing to administer methylergonovine IM for a client who had a vaginal delivery earlier that day. The nurse should explain to the client that this medication will help prevent which of the following?

9 :
A nurse is reinforcing teaching with a client who takes lithium carbonate for bipolar disorder. For which of the following findings should the nurse monitor as an adverse effect of lithium carbonate?

10 :
A nurse is collecting data from a client who takes several daily medications and states that he wants to ask the provider for a prescription for sildenafil. The nurse knows that sildenafil is contraindicated due to an interaction with which of the following client's medications?