The client received a drug that caused an unexpected and unusual effect. Which term does the nurse use to describe this effect?
1. Toxic
2. Allergic
3. Therapeutic
4. Idiosyncratic
4
4. An unusual, unexpected side effect of a medication is an idiosyncratic effect.
1. Toxic medication effects occur with prolonged therapy, excessive dosing, or im-paired metabolism or systemic accumulation in the client. They are adverse effects with the potential to cause client injury and death.
2. Allergic reactions are unpredictable, unless the client has a history of a medication allergy, and result from an immunologic client response to the medication involving antibody formation.
3. A therapeutic response is a desirable client response or the intended response.
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Which measure may prevent mastitis in a breastfeeding client?
a. Wearing a tight-fitting bra b. Applying ice packs prior to feeding c. Initiating early and frequent feedings d. Nursing the infant for 5 minutes on each breast
In what age group would a nurse expect to assess the most rapid respiratory rate?
A) older adults B) middle adults C) adolescents D) infants
A gravida 3, para 2 woman at 41 weeks' gestation is 1 cm dilated and 60% effaced. She has not ruptured her membranes, has not passed a mucus plug, and is not experiencing labor
It is decided that if she does not experience labor by the next day, she will be induced with oxytocin (Pitocin). Which actions are key to the nursing care of a woman experiencing induction? (Select all that apply.) a. Provide an explanation of all procedures to the client. b. Monitor mother's vital signs throughout the procedure. c. Insert and monitor arterial blood pressure via an inserted arterial line. d. Continuously monitor fetal toleration to the induction. e. Insert a Foley catheter and monitor hourly urine outputs. f. Assess for obstetric complications and notify physician as warranted. g. Monitor the intravenous infusion of medication. h. Continue to increase dosage, titrating until fetal distress is marked.
An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "My mother often wanders at night. Last night she fell down the stairs."
Which nursing diagnosis has priority? a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision b. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls c. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering d. Insomnia related to sleep disruptions associated with cognitive impairment as evidenced by wandering at night