A nurse is monitoring a client who has a head injury and is receiving mannitol 25% via IV infusion. The nurse should identify which of the following as an adverse effect of the medication and report to the provider?
Glasgow coma scale rating of 15
Crackles on auscultation
Increase in urinary output
Intracranial pressure reading of 12mm
The Correct Answer is B
A. Glasgow Coma Scale rating of 15: A Glasgow Coma Scale (GCS) rating of 15 is a positive sign indicating that the client is fully conscious and oriented. It is not an adverse effect of mannitol.
B. Crackles on auscultation: Crackles, also known as rales, can indicate fluid overload or pulmonary edema, which can be an adverse effect of mannitol. Mannitol can cause shifts of fluid, including into the lungs, leading to pulmonary edema.
C. Increase in urinary output: Mannitol is an osmotic diuretic, and an increase in urinary output is an expected and therapeutic effect of the medication. It is not considered an adverse effect.
D. Intracranial pressure reading of 12 mmHg: A decrease in intracranial pressure is a therapeutic effect of mannitol, and a reading of 12 mmHg is generally within a normal range. It is not considered an adverse effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["400"]
Explanation
Step 1: Determine the Total Volume Needed
- Supplied concentration: 300 mg/100 mL
- Prescribed dose: 300 mg
- Total volume needed = 100 mL
Step 2: Convert Time to Hours
- Prescribed infusion time = 15 minutes
- 15 minutes ÷ 60 minutes/hour = 0.25 hours
Step 3: Calculate the Infusion Rate (mL/hr)
- Infusion rate = Total volume (mL) ÷ Time (hours)
- Infusion rate = 100 mL ÷ 0.25 hours
- Infusion rate = 400 mL/hr
The nurse should set the IV pump to deliver cimetidine at 400 mL/hr (rounded to the nearest whole number).
Correct Answer is D
Explanation
A. Increased blood pressure: Heparin does not typically directly affect blood pressure. However, if there are other underlying conditions or complications related to the reason for heparin use, it might indirectly influence blood pressure. But a high aPTT level itself wouldn't directly cause an increase in blood pressure.
B. Decreased temperature: Heparin does not usually affect body temperature. Changes in temperature might occur due to other factors, but they are not directly related to heparin administration or its effects on aPTT.
C. Decreased respiratory rate: Heparin does not typically affect the respiratory rate directly. Changes in respiratory rate might occur due to other causes but are not directly correlated with heparin administration or its effects on aPTT.
D. Increased pulse rate: Heparin, especially when aPTT is elevated, might indicate that the blood is less likely to clot. An increased pulse rate could be indicative of compensatory mechanisms due to potential bleeding or changes in clotting factors influenced by heparin. It's essential to monitor for an increased pulse rate as a potential sign of bleeding complications associated with anticoagulant therapy.
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