A nurse is caring for a client who is receiving high-dose metalopramide. The nurse should monitor the client for which of the following adverse effects?

Black stools

Dry cough

Oral candidias

Tardive dyskinesia

Answer and Explanation

The Correct Answer is D

A) Black stools: While black stools can be a potential side effect of gastrointestinal bleeding, it is not commonly associated with high-dose metoclopramide. This side effect is more commonly seen with medications such as aspirin or NSAIDs. Therefore, it is not the most pertinent adverse effect to monitor for with high-dose metoclopramide.

B) Dry cough: Dry cough is not a typical adverse effect of metoclopramide. Cough is more commonly associated with medications such as ACE inhibitors. Therefore, it is not the primary adverse effect to monitor for with high-dose metoclopramide.

C) Oral candidiasis: While oral candidiasis (oral thrush) can occur as a side effect of some medications, it is not commonly associated with metoclopramide. Oral candidiasis is more frequently seen with corticosteroids or antibiotics. Therefore, it is not the primary adverse effect to monitor for with high-dose metoclopramide.

D) Tardive dyskinesia: Tardive dyskinesia is a serious adverse effect associated with prolonged use of edicaopramide, especially at high doses. It is characterized by involuntary, repetitive movements of the face, tongue, or other parts of the body. Monitoring for signs and symptoms of tardive dyskinesia, such as repetitive facial grimacing or tongue protrusion, is crucial when administering high-dose metoclopramide to prevent this potentially irreversible condition. Therefore, this is the correct adverse effect to monitor for in clients receiving high-dose metoclopramide.

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Correct Answer is A

Explanation

A) Respirations deep at a rate of 10/min: This finding indicates respiratory depression, which is a significant concern with morphine administration. Respiratory depression can lead to hypoxia and respiratory arrest, posing a life-threatening situation for the client. Therefore, it is the priority finding that requires immediate intervention, such as reducing the dose of morphine, administering naloxone (an opioid antagonist), or providing respiratory support.

B) Urinary output of 20 mL within 1 hr: While decreased urinary output may indicate potential renal impairment or dehydration, it is not as immediately life-threatening as respiratory depression. However, it should still be monitored and addressed appropriately.

C) Vomiting 30 mL of fluid: Vomiting can be a side effect of morphine but may not require immediate intervention unless it leads to aspiration or dehydration. Nonetheless, it should be closely monitored for complications.

D) Blood pressure 90/60 mm Hg: Hypotension can occur as a side effect of morphine due to its vasodilatory effects. While low blood pressure should be addressed, it is not as immediately life-threatening as respiratory depression. Monitoring and appropriate interventions, such as fluid administration or adjusting the dose of morphine, can be implemented to manage hypotension.

A. Expel the air bubble from the syringe prior to administering the medication. B. Administer the medication into the anterolateral or posterolateral abdominal area. C. Hold the skin taut at the injection site while administering the medication. D. Massage the injection site after administering the medication.

Correct Answer is B

Explanation

A) Ex edicationr bubble from the syringe prior to administering the medication: Expelling air bubbles is necessary when administering medications via intravenous injection to prevent air embolisms. However, with subcutaneous injections like enoxaparin, the presence of small air bubbles is not usually a concern, and expelling them is not necessary.

B) Administer the medication into the anterolateral or posterolateral abdominal area: This is the correct action for administering enoxaparin. Enoxaparin is typically administered subcutaneously into the anterolateral or posterolateral abdominal wall. This site is preferred due to its high vascularity and good absorption of the medication.

C) Hold the skin taut at the injection site while administering the medication: While holding the skin taut can help reduce discomfort during the injection, it is not always necessary. The choice to hold the skin taut depends on the client's body habitus and the nurse's preferenc’. It is not a specific requi’ement for administering enoxaparin.

D) Massage the injection site after administering the medication: Massaging the injection site after administering enoxaparin is not recommended. It can increase bruising or bleeding at the injection site. Instead, after administering the medication, the nurse should apply gentle pressure with a dry cotton ball or gauze pad to help minimize bleeding.

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A nurse is caring for a client who is receiving high-dose metalopramide. The nurse should monitor the client for which of the following adverse effects?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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