Choice A rationale:

Donepezil is a medication used to treat symptoms of Alzheimer’s disease and does not typically cause urinary retention.

Choice B rationale:

Scopolamine, an anticholinergic drug, can cause urinary retention. Anticholinergic drugs block the action of acetylcholine, a neurotransmitter that helps to contract the bladder muscles and relax the urinary sphincters to allow urination.

Choice C rationale:

Metoprolol is a beta-blocker used to treat high blood pressure and heart problems. It does not typically cause urinary retention.

Choice D rationale:

Acetaminophen is a common over-the-counter pain reliever and does not typically cause urinary retention.

Choice A rationale:

While it’s important for the provider to be informed if the medication isn’t working, it’s premature to change the medication after only 6 days.

Choice B rationale:

Amitriptyline does not need to be taken on an empty stomach to be effective.

Choice C rationale:

Amitriptyline, a tricyclic antidepressant, often takes several weeks before a therapeutic effect is felt.

Choice D rationale:

Increasing the dose prematurely can lead to unnecessary side effects. It’s better to wait for the medication to take effect.

Choice A rationale:

Fish oil supplements do not have a known interaction with levothyroxine.

Choice B rationale:

Calcium supplements can interfere with the absorption of levothyroxine. They should be taken at least four hours apart from levothyroxine.

Choice C rationale:

While bulk-forming laxatives can interfere with the absorption of some medications, there’s no specific evidence they interfere with levothyroxine.

Choice D rationale:

Oral antihistamines do not have a known interaction with levothyroxine.

Choice A rationale:

AST (Aspartate Aminotransferase) is a liver enzyme and its levels are used to assess liver function, not the effectiveness of epoetin alfa.

Choice B rationale:

Troponin is a cardiac marker used to diagnose heart attacks. It has no relation with the effectiveness of epoetin alfa.

Choice C rationale:

T4 (Thyroxine) is a thyroid hormone. Its levels indicate thyroid function, not the effectiveness of epoetin alfa.

Choice D rationale:

Hgb (Hemoglobin) levels are used to assess the effectiveness of epoetin alfa. Epoetin alfa is a medication that stimulates the production of red blood cells, thereby increasing hemoglobin levels in the blood. Normal hemoglobin levels are 13.5 to 17.5 g/dL in men and 12.0 to 15.5 g/dL in women.

Choice A rationale:

A respiratory rate of 10/min is lower than the normal range (12-20 breaths per minute for adults), indicating respiratory depression, which is a serious side effect of morphine and should be reported immediately.

Choice B rationale:

Facial flushing is a common side effect of morphine due to histamine release but it’s not life-threatening.

Choice C rationale:

Constipation is a common side effect of morphine and can be managed with laxatives and diet.

Choice D rationale:

Blood pressure 88/56 mm Hg is lower than the normal range (90/60mmHg to 120/80mmHg), indicating hypotension, which can be a side effect of morphine but it’s not as immediately life-threatening as respiratory depression.

Choice A rationale:

Hydrochlorothiazide is a diuretic medication and does not interfere with the absorption of tetracycline.

Choice B rationale:

Antacids can interfere with the absorption of tetracycline, reducing its effectiveness. Therefore, they should be taken 3 hours before or after taking tetracycline.

Choice C rationale:

Lovastatin is a lipid-lowering medication and does not interfere with the absorption of tetracycline.

Choice D rationale:

Acetaminophen is an analgesic and does not interfere with the absorption of tetracycline.

Choice A rationale:

A negative mammogram is not a requirement of the iPLEDGE program. Mammograms are used to screen for breast cancer and are not related to isotretinoin therapy.

Choice B rationale:

Regular Papanicolaou tests, which screen for cervical cancer, are not a requirement of the iPLEDGE program. These tests are not related to isotretinoin therapy.

Choice C rationale:

There is no requirement for clients to begin a daily supplement of vitamin A prior to initiating therapy. In fact, taking additional vitamin A while on isotretinoin can increase the risk of vitamin A toxicity.

Choice D rationale:

Sexually active female clients must use two forms of birth control during treatment. This is because isotretinoin can cause severe birth defects.

Choice A rationale:

Fever is not a common side effect of acetaminophen. In fact, acetaminophen is often used to reduce fever.

Choice B rationale:

Jaundice, which is a yellowing of the skin or eyes, can be a sign of liver damage, a rare but serious side effect of acetaminophen.

Choice C rationale:

Diarrhea is not a common side effect of acetaminophen.

Choice D rationale:

Tinnitus, or ringing in the ears, is not a common side effect of acetaminophen.

Choice Arationale:

Aspiration (pulling back on the syringe before injection) is not recommended when administering enoxaparin. This could cause bruising.

Choice Brationale:

You should not massage the site following the injection as this could cause bruising.

Choice Crationale:

With enoxaparin and other low molecular weight heparins, you do not need to expel the air bubble before injecting the medication. The air bubble ensures that all the medication is delivered.

Choice D rationale:

Enoxaparin should be injected into abdominal tissue. This helps ensure proper absorption and reduces the risk of bruising.

Choice A rationale:

Consulting a pharmaceutical sales representative is not the best option. While they are knowledgeable about the medications they promote, their primary role is to market their company’s products, and they may not have comprehensive information about other medications.

Choice B rationale:

While a nursing team member can be a valuable resource, they may not have the specific knowledge about the medication in question. It’s also important to remember that medication information can change frequently, and relying on another person’s knowledge may lead to errors.

Choice C rationale:

The client’s family can provide useful information about how the client has been taking the medication at home, but they are unlikely to have detailed pharmacological knowledge about the medication.

Choice D rationale:

A nursing drug guide is a reliable and up-to-date resource that provides comprehensive information about medications, including indications, contraindications, dosages, potential side effects, and interactions. Therefore, when unfamiliar with a medication, the nurse should consult a nursing drug guide.

Choice A rationale:

Dissolving the medication in 30 mL of water is the correct action. This ensures that the medication is in a suitable form for administration via an NG tube and helps prevent the tube from becoming blocked.

Choice B rationale:

Maintaining the client in the supine position during medication administration is not recommended. This position increases the risk of aspiration. Instead, the client should be in an upright position during medication administration and for at least 30 minutes afterward.

Choice C rationale:

Adding the medication to the enteral feeding formula is not recommended. This can alter the effectiveness of the medication and can also clog the feeding tube.

Choice D rationale:

Flushing the tube with 5 mL of water after administering the medication is not enough. The tube should be flushed with at least 15-30 mL of water before and after medication administration to ensure that the entire dose has been administered and to prevent clogging of the tube.

Choice A rationale:

Hypotension is not typically a symptom of withdrawal from diazepam. Withdrawal from diazepam, a benzodiazepine, usually results in symptoms opposite to its therapeutic effects.

Choice B rationale:

Drowsiness is not a symptom of withdrawal from diazepam. In fact, insomnia or difficulty sleeping may occur during withdrawal.

Choice C rationale:

Anorexia or loss of appetite may occur during withdrawal from some substances but it’s not typically associated with benzodiazepine withdrawal.

Choice D rationale:

Tremors are a common symptom of withdrawal from diazepam. Other symptoms can include anxiety, restlessness, irritability, and even seizures in severe cases.

Choice A rationale:

An apical pulse of 54/min is below the normal range for adults. Digoxin, a cardiac medication, can lower the heart rate. Therefore, it’s crucial to hold the medication if the resting pulse for an adult is less than 60 bpm. This is to prevent further lowering of the heart rate which could lead to bradycardia, a potentially dangerous condition.

Choice B rationale:

A respiratory rate of 14/min is within the normal adult range of 12-20 breaths per minute. This would not be a reason to withhold digoxin.

Choice C rationale:

A blood pressure (BP) of 179/89 mm Hg indicates hypertension, which is not a direct contraindication for digoxin. However, it’s important to monitor BP levels in clients taking digoxin as the medication can affect blood pressure.

Choice D rationale:

A temperature of 37.8° C (100° F) is slightly elevated but would not be a reason to withhold digoxin unless it’s indicative of an underlying infection that needs to be addressed first.

Choice A rationale:

While headache can be a side effect of aspirin, it’s usually not severe enough to warrant reporting to the provider unless it’s persistent or severe.

Choice B rationale:

Rhinitis, or inflammation of the mucous membrane of the nose, can be an allergic reaction to aspirin and should be reported to the provider.

Choice C rationale:

Hematocrit (Hct) level of 43% is within the normal range for both men (38.8–50.0 %) and women (34.9–44.5 %), so this finding would not need to be reported.

Choice D rationale:

A blood pressure reading of 120/70 mm Hg is within the normal range and would not need to be reported.

Choice A rationale:

Instructing the client to chew the medication is not recommended for enteric-coated tablets as it could result in stomach upset or damage to the protective coating.

Choice B rationale:

Placing the medication on the client’s tongue allows for easier swallowing without compromising the integrity of the enteric coating.

Choice C rationale:

Dissolving the medication in juice is not recommended as it could damage the enteric coating and result in stomach upset.

Choice D rationale:

Placing the medication between the client’s cheek and gum is not typically recommended for enteric-coated tablets as it could result in discomfort or damage to the protective coating.

Choice A rationale:

Oxycodone overdose typically results in constricted (not dilated) pupils due to its action on the central nervous system.

Choice B rationale:

Oxycodone overdose can cause respiratory depression, leading to slow and shallow breathing (bradypnea), not rapid breathing (tachypnea)

Choice C rationale:

Oxycodone does not typically cause tachycardia. It can cause bradycardia due to its action on the central nervous system.

Choice D rationale:

Sedation is a common effect of oxycodone and can be more pronounced in cases of overdose due to the drug’s depressant effect on the central nervous system.

Choice A rationale:

Fluoxetine is an antidepressant. While some antidepressants are used for chronic pain management, fluoxetine is not typically used for this purpose.

Choice B rationale:

Methylphenidate is a stimulant used to treat attention deficit hyperactivity disorder (ADHD) and is not used for pain management.

Choice C rationale:

Lorazepam is a benzodiazepine used for treating anxiety, seizures, and insomnia. It is not typically used for managing neuralgia pain.

Choice D rationale:

Carbamazepine is an anticonvulsant that is commonly used to manage trigeminal neuralgia. It helps to reduce nerve impulses that cause pain.

Choice Arationale:

Flaxseed is a rich source of omega-3 fatty acids and can have anti-inflammatory effects. It does not have any known contraindications with SLE.

Choice B rationale:

Glucosamine is often used to support joint health. It is not contraindicated in clients with SLE and may actually provide some benefits in terms of reducing joint pain and stiffness.

Choice C rationale:

Echinacea is an herbal supplement that is often used to boost the immune system. However, in clients with autoimmune disorders like SLE, boosting the immune system can actually exacerbate the disease. Therefore, Echinacea is contraindicated in clients with SLE.

Choice Drationale:

Ginger is a common herbal supplement that is often used for its anti-inflammatory and anti-nausea effects. It does not have any known contraindications with systemic lupus erythematosus (SLE)

Choice A rationale:

Hoarseness of voice can be a symptom of an allergic reaction, indicating swelling and inflammation in the throat. If the client’s voice is no longer hoarse after taking diphenhydramine, it suggests that the medication has been effective in reducing this symptom.

Choice B rationale:

Diphenhydramine is an antihistamine and can often cause drowsiness as a side effect. Therefore, feeling more alert would not typically indicate that the medication has been effective.

Choice C rationale:

While headaches can sometimes be associated with allergic reactions, they are not a primary symptom that diphenhydramine targets. Therefore, absence of a headache does not necessarily indicate effectiveness of the medication.

Choice D rationale:

Increased appetite is not typically associated with the effectiveness of diphenhydramine in treating allergic reactions.

Choice A rationale:

Fexofenadine can be taken with or without food, and there are no specific interactions with magnesium hydroxide. However, it’s always important to consult a healthcare provider before combining medications.

Choice B rationale:

While staying hydrated is generally good advice, there’s no specific requirement to drink up to one liter of fluid per day while taking fexofenadine.

Choice C rationale:

Fexofenadine should not be taken with fruit juices such as orange juice because they can decrease the absorption of the medication, making it less effective.

Choice D rationale:

Fexofenadine can cause side effects such as dizziness or drowsiness in some people. Therefore, it’s important to avoid driving or operating heavy machinery until you know how this medication affects you.

Choice A rationale:

Administering an IV fluid bolus can help increase blood volume and thus increase blood pressure, which can alleviate symptoms of dizziness and lightheadedness. This is a common side effect of ramipril, especially after the first dose.

Choice B rationale:

Naloxone is an opioid antagonist and is not relevant in this context. It’s used to reverse the effects of opioid overdose, not to treat symptoms associated with antihypertensive medications.

Choice C rationale:

Diphenhydramine is an antihistamine used to treat allergic reactions or insomnia, not symptoms associated with antihypertensive medications.

Choice D rationale:

Administering 15 g of carbohydrates would be appropriate for a hypoglycemic patient, not for a patient experiencing dizziness and lightheadedness due to antihypertensive medication.

Choice A rationale:

Checking blood pressure with the client standing could exacerbate the client’s symptoms due to orthostatic hypotension, which is a common side effect of captopril.

Choice B rationale:

Administering a 0.9% sodium chloride IV bolus could be considered if the client’s blood pressure does not improve with positioning changes or if the client’s condition worsens.

Choice C rationale:

Placing the client in a supine position can help increase blood flow to the brain and alleviate symptoms of low blood pressure. This should be the first action taken by the nurse.

Choice D rationale:

Measuring blood pressure with the client sitting could also exacerbate symptoms due to orthostatic hypotension. It would be more appropriate after the client’s condition has stabilized.

Choice A rationale:

While a tuberculin syringe can be used for insulin administration, it’s not necessary when mixing NPH and regular insulin. Insulin syringes are typically used for this purpose.

Choice B rationale:

Injecting air into each vial before withdrawing insulin helps equalize pressure and makes it easier to draw up the insulin. This should be done before withdrawing any insulin.

Choice C rationale:

Withdrawing NPH insulin first contradicts the standard practice of drawing up insulins. The usual recommendation is to draw up short-acting (regular) insulin before intermediate-acting (NPH) insulin.

Choice D rationale:

Shaking the regular insulin vial is unnecessary and could potentially create bubbles, making it harder to draw up the correct dose of insulin.

Choice A rationale:

Atenolol is a beta-blocker used to treat high blood pressure and heart-related conditions. It’s not used in the treatment of alcohol use disorder.

Choice B rationale:

Lorazepam is a benzodiazepine used to treat anxiety disorders. It can be used in the acute management of alcohol withdrawal, but it doesn’t assist in maintaining abstinence.

Choice C rationale:

Disulfiram is a medication used to support the treatment of chronic alcoholism by producing an acute sensitivity to ethanol (drinking alcohol) If alcohol is consumed when a patient has received disulfiram treatment, they suffer from a disulfiram-alcohol reaction, which can include symptoms like flushing, nausea, vomiting, and headaches. This aversive effect aids in discouraging the consumption of alcohol.

Choice D rationale:

Carbamazepine is an anticonvulsant and mood stabilizer medication used primarily in the treatment of epilepsy and bipolar disorder, not for alcohol use disorder.

Choice A rationale:

The first dose of the varicella vaccine is usually given when the child is between 12 to 15 months old, not after 3 years.

Choice B rationale:

Aspirin should not be given to children due to the risk of Reye’s syndrome. This syndrome is a rare but serious condition that causes swelling in the liver and brain.

Choice C rationale:

The varicella vaccine should be avoided in children who have leukemia or any other condition that weakens the immune system.

Choice D rationale:

The varicella vaccine is not contraindicated for children who are allergic to eggs. It’s some other vaccines like influenza that have this restriction.