The nurse assesses hives in a patient started on a new medication. What is the nurse's priority action?
a. Notify physician of allergic reaction.
b. Notify physician of idiosyncratic reaction.
c. Notify physician of potential teratogenicity.
d. Notify physician of potential tolerance.
ANS: A
An allergic reaction is indicative of hypersensitivity and manifests with hives and/or urticaria, which are easily identified. An idiosyncratic reaction occurs when something unusual or abnormal happens when a drug is first administered. A teratogenic reaction refers to the occurrence of birth defects related to administration of the drug. Tolerance refers to the body's requirement for increasing dosages to achieve the same effects that a lower dose once did.
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While evaluating a client's electrocardiogram (ECG) before surgery, the preoperative nurse identifies large, wide Q waves. What is the nurse's best interpretation of this finding?
a. An acute myocardial infarction is occur-ring. b. The client had a myocardial infarction in the past. c. The ventricles are enlarged and failing. d. The ECG is a common variation of normal sinus rhythm.
A child has been diagnosed with cat scratch disease. The nurse explains which characteristics about this disease?
a. "The disease is usually a benign, self-limiting illness." b. "The animal that transmitted the disease will also be ill." c. "The disease is treated with a 5-day course of oral azithromycin." d. "Symptoms include pruritus, especially at the site of inoculation."
The school nurse is talking with caregivers and school-aged girls about the prevention of urinary tract infections. Which of the following teachings will be most helpful in preventing urinary tract infections?
a. "Children will benefit from warm bubble baths to keep the external urinary openings clean." b. "Have the children wear nylon underwear rather than cotton underwear." c. "Girls should always wipe with the toilet tissue from front to back and never from back to front." d. "Children can learn to hold their urine for 3-4 hours to strengthen the bladder muscle tone."
The client receives hydrocortisone therapy. The nurse will primarily assess for which electrolyte disturbance?
1. Hypernatremia and hyperglycemia 2. Hypernatremia and hyperkalemia 3. Hypocalecmia and hyperkalemia 4. Hypoglycemia and hyponatremia