A nurse is assessing a client who is receiving gemfibrozil. The nurse should identify which of the following findings as an adverse effect of this medication?
Dependent edema.
Muscle tenderness.
Tremors.
Hyperkalemia.
The Correct Answer is B
Choice A rationale
Dependent edema is not a common adverse effect of gemfibrozil. It is more commonly associated with other conditions such as heart failure.
Choice B rationale
Muscle tenderness is a known adverse effect of gemfibrozil. It can indicate myopathy or rhabdomyolysis, which are serious conditions that require medical attention.
Choice C rationale
Tremors are not a common adverse effect of gemfibrozil. They are more commonly associated with neurological conditions or other medications.
Choice D rationale
Hyperkalemia is not a common adverse effect of gemfibrozil. It is more commonly associated with medications that affect renal function or potassium balance. .
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Correct Answer is ["A","B","C","D","F"]
Explanation
Choice A rationale
Assessing the client’s gag reflex before offering oral intake is essential to prevent aspiration. The gag reflex may be diminished after moderate sedation and the use of local anesthetics during bronchoscopy.
Choice B rationale
Listening to the client’s breath sounds is important to detect any abnormalities, such as wheezing, crackles, or decreased breath sounds, which could indicate complications like bronchospasm or pneumothorax.
Choice C rationale
Monitoring the client’s oxygen saturation is crucial to ensure adequate oxygenation and detect any signs of respiratory distress or hypoxemia following the procedure.
Choice D rationale
Monitoring the client for manifestations of bleeding is necessary because bronchoscopy can cause trauma to the airways, leading to bleeding. Signs of bleeding may include hemoptysis or a drop in hemoglobin levels.
Choice E rationale
Assessing the client’s puncture site is not applicable in this context, as bronchoscopy does not involve a puncture site. This option is incorrect.
Choice F rationale
Observing the client for manifestations of a pneumothorax is important because bronchoscopy can occasionally cause a pneumothorax, especially if a biopsy is performed. Signs of pneumothorax include sudden chest pain, dyspnea, and decreased breath sounds on the affected side. .
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Contacting the provider is essential to inform them of the error and receive further instructions on managing the client’s condition.
Choice B rationale
Reporting the error to the charge nurse is necessary for proper documentation and to ensure that corrective actions are taken to prevent future errors.
Choice C rationale
Incident reports should not be placed in the client’s chart. They are for internal use to improve safety and quality of care.
Choice D rationale
Auscultating the client’s lungs is important to check for signs of fluid overload, such as crackles or wheezing.
Choice E rationale
Checking for peripheral edema helps assess the extent of fluid overload and its impact on the client’s condition.