A nurse is evaluating a client who received subcutaneous sumatriptan 1 hour ago. Which of the following findings should the nurse identify as an adverse effect of the medication?

Visual disturbances

Pressure in the chest

Phonophobia

Numbness of the tongue

Answer and Explanation

The Correct Answer is B

A. Visual disturbances: Visual changes can occur as part of a migraine aura, but they are not typically an adverse effect caused by sumatriptan itself.

B. Pressure in the chest: Sumatriptan can cause vasoconstriction, leading to chest pressure or tightness. This cardiovascular effect is a known adverse reaction and should be assessed carefully to rule out serious complications.

C. Phonophobia: Sensitivity to sound is a symptom of migraines, not a side effect of sumatriptan. It reflects the underlying condition rather than medication-related adverse effects.

D. Numbness of the tongue: Tingling or paresthesia can occur in some clients, but numbness of the tongue is less common and not a primary adverse effect of sumatriptan compared with cardiovascular symptoms.

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Correct Answer is C

Explanation

A. Protamine sulfate: Protamine sulfate is an antidote for heparin overdose, not for aspirin toxicity. It does not address salicylate-related symptoms such as tinnitus.

B. Diphenhydramine: Diphenhydramine is an antihistamine used for allergic reactions and motion sickness. It does not counteract aspirin toxicity or reduce salicylate levels.

C. Bicarbonate: Sodium bicarbonate is used in cases of aspirin (salicylate) toxicity to alkalinize the urine, which enhances the renal excretion of salicylates. This intervention helps reduce systemic toxicity, including symptoms like tinnitus.

D. Naloxone: Naloxone is an opioid antagonist used for opioid overdose. It has no effect on aspirin toxicity or salicylate-induced symptoms.

A. A client receives regular insulin 1 hr after a meal. B. A client refuses to get out of bed. C. A client was scheduled to be discharged 2 hr ago. D. A client receives an antibiotic 30 min after the scheduled time.

Correct Answer is A

Explanation

A. A client receives regular insulin 1 hr after a meal: Administering insulin outside the recommended timing can cause hypoglycemia or other adverse effects. This medication error is a reportable event, requiring completion of an incident report for documentation and quality improvement.

B. A client refuses to get out of bed: Patient refusal of activity or care is part of routine nursing documentation and does not constitute an incident that requires a formal report unless it results in harm.

C. A client was scheduled to be discharged 2 hr ago: A delayed discharge is an operational issue rather than a clinical incident. It should be addressed in workflow review but does not require an incident report.

D. A client receives an antibiotic 30 min after the scheduled time: A slight delay in routine medication administration is typically documented in the medical record but does not usually meet the threshold for an incident report unless it results in harm or adverse effects.

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A nurse is evaluating a client who received subcutaneous sumatriptan 1 hour ago. Which of the following findings should the nurse identify as an adverse effect of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking aspirin and reports having tinnitus. Which of the following medications should the nurse expect to administer?

Correct Answer is C

Explanation

A nurse is caring for a group of clients. For which the following situations should the nurse complete an incident report?

Correct Answer is A

Explanation

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