A nurse is administering medications to a client and mistakenly gives hydroxyzine instead of hydralazine. For which of the following adverse effects should the nurse monitor the client?
Sedation
Drooling
Diarrhea
Hypertension
The Correct Answer is A
Hydroxyzine is a first-generation antihistamine that crosses the blood-brain barrier, leading to significant anticholinergic and sedative effects. In contrast, hydralazine is a peripheral vasodilator used for hypertension. This look-alike, sound-alike error involves switching a sedative for an antihypertensive, requiring close neurological and cardiovascular monitoring.
Rationale:
A. Sedation is a primary adverse effect of hydroxyzine due to its ability to block H1 receptors in the central nervous system. Because the client received this instead of a blood pressure medication, the nurse must monitor for extreme drowsiness, dizziness, and a possible risk for falls. Sedation is the most immediate and expected neurological consequence of this specific medication error.
B. Drooling is not associated with hydroxyzine; rather, this medication has anticholinergic properties that typically cause dry mouth (xerostomia). Hydroxyzine reduces secretions and blocks parasympathetic activity, making drooling an unlikely finding. If the client experiences drooling, the nurse should investigate other causes, such as neurological impairment or the effect of different pharmacological agents.
C. Diarrhea is not a common side effect of hydroxyzine administration. Antihistamines with anticholinergic effects are more likely to cause constipation due to slowed gastrointestinal motility. The nurse should monitor for decreased bowel sounds rather than increased frequency of stools. Diarrhea would be an atypical response to the mistaken administration of an antihistamine.
D. While hydralazine (the intended drug) treats hypertension, the nurse should monitor for high blood pressure because the client missed their antihypertensive dose. However, the prompt asks for the adverse effect of the medication actually given. Hydroxyzine itself does not cause hypertension; instead, the primary risk of the drug actually administered is central nervous system depression and potential hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Disulfiram is an aldehyde dehydrogenase inhibitorused as an aversion therapy for alcohol use disorder. It causes the accumulation of acetaldehydein the blood if ethanol is consumed, leading to a highly unpleasant and dangerous disulfiram-ethanol reaction. This reaction can escalate from mild discomfort to cardiovascular collapse and respiratory failure.
Rationale:
A.A headache is a distressing part of the disulfiram-ethanol reaction, but it is not the most life-threatening symptom. While the client may experience significant throbbing and pain, the nurse must prioritize the assessment of ABCs (airway, breathing, and circulation). A headache does not signal the immediate hemodynamic instability that requires the highest level of emergency medical intervention.
B.Flushing of the face and neck occurs due to acetaldehyde-induced vasodilation and is one of the first signs of the reaction. While visually prominent, flushing itself does not pose an immediate threat to the client’s life. The nurse should document the finding but focus on identifying more severe symptoms that indicate the client is entering a stage of cardiovascular shock.
C.Hypotension is the priority finding because it indicates severe cardiovascular collapse resulting from profound vasodilation and increased capillary permeability. Significant drops in blood pressure during a disulfiram reaction can lead to shock, myocardial infarction, or death. The nurse must report this immediately so that emergency resuscitation, including intravenous fluids and vasopressors, can be initiated to stabilize the client.
D.Nausea and vomiting are very common during the disulfiram-ethanol reaction and serve as the primary "aversion" mechanism of the drug. Although these symptoms are highly uncomfortable and can lead to dehydration, they are not as immediately fatal as profound hypotension. The nurse should manage the vomiting but prioritize reporting the signs of circulatory failure to the healthcare provider.
Correct Answer is B
Explanation
Methylergonovine is an ergot alkaloidused to manage postpartum hemorrhage by inducing firm, sustained uterine contractions. It acts directly on the uterine smooth muscle but also possesses significant vasoconstrictive properties. Because it can cause a rapid and dangerous rise in systemic vascular resistance, it is strictly contraindicated in patients with hypertensive disorders.
Rationale:
A.Lochia rubra is the normal, bloody vaginal discharge observed in the immediate postpartum period and is not a contraindication for methylergonovine. In fact, if the lochia is excessive due to uterine atony (a boggy fundus), methylergonovine is indicated to stop the bleeding. The medication helps transition the uterus to a firm state, which actually reduces the volume of lochia rubra.
B.A blood pressure of 190/110 mm Hg is a critical contraindication because methylergonovine causes systemic arterial vasoconstriction. Administering this medication to a hypertensive patient could lead to a stroke, myocardial infarction, or seizure. The nurse must withhold the dose and notify the provider, as this drug can exacerbate pre-eclampsia or chronic hypertension to life-threatening levels.
C.A distended bladder can cause the uterus to become boggy by displacing it upward and to the side, but it does not contraindicate methylergonovine. While the nurse should encourage the patient to void to allow for natural uterine contraction, the presence of a full bladder does not make the drug unsafe. Clinical priority involves emptying the bladder to accurately assess fundal tone.
D.A urinary output of 60 mL/hr is a normal physiological finding and indicates adequate renal perfusion in the postpartum patient. There is no pharmacological reason to withhold methylergonovine based on this healthy urine volume. The nurse should continue to monitor output, but 60 mL/hr suggests the patient is hemodynamically stable and capable of clearing medications through the kidneys.
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