Medication and IV Administration

Typical needle length for subcutaneous

1/2 to 5/8 inches (1.3 to 1.6 cm) in length

neuroleptic malignant syndrome

Adverse reaction to antipsychotics with severe "lead pipe" rigidty, FEVER, and mental status changes

As she tries to decide on a birth control method, a client requests information about medroxyprogesterone. Which statement represents the nurse's best response? A. "Medroxyprogesterone needs to be administered every 12 weeks." B. "Medroxyprogesterone is effective for only 2 months at a time." C. "Medroxyprogesterone can't be given to breast-feeding women." D. "Medroxyprogesterone has a high failure rate; use a barrier form of protection also."

Correct response: "Medroxyprogesterone needs to be administered every 12 weeks." Explanation: Medroxyprogesterone will provide effective birth control for 3 months, and it may be the birth-control method of choice for clients who are breast-feeding because studies haven't established any contraindications. There is no evidence that the drug has a high failure rate.

The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should perform the actions in order of what priority from first to last? All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. -Position rolled towel under client's back, parallel to the spine. -Change dressing per institutional policy. -Obtain a culture from the drainage at the insertion site. -Notify the health care provider.

Correct response: -Notify the health care provider. -Position rolled towel under client's back, parallel to the spine. -Obtain a culture from the drainage at the insertion site. -Change dressing per institutional policy. Explanation: A potential complication of receiving TPN is leakage or catheter puncture; the nurse should first notify the health care provider and prepare for changing of the catheter. Next, if pneumothorax is suspected, position a rolled towel under the client's back. If there is drainage at the insertion site, the nurse should then obtain a culture from the drainage and lastly, change the dressing using sterile technique.

A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of [800 mg/dl (44.4 mmol/L)]. Which solution is the most appropriate at the beginning of therapy? -100 units of regular insulin in normal saline solution -100 units of neutral protamine Hagedorn (NPH) insulin in normal saline solution -100 units of regular insulin in dextrose 5% in water -100 units of NPH insulin in dextrose 5% in water

Correct response: 100 units of regular insulin in normal saline solution Explanation: Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia.

What is the main advantage of using a floor stock system? A nurse can implement medication orders quickly. A nurse receives input from the pharmacist. The system minimizes transcription errors. The system reinforces accurate calculations.

Correct response: A nurse can implement medication orders quickly. Explanation: A floor stock system enables a nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.

A child newly diagnosed with rheumatic fever is to receive penicillin therapy. Which statement by the parents should lead the nurse to judge that the parents understand the teaching about penicillin as part of the treatment plan? A. "Our child should take the medication until the primary health care provider discontinues it." B. "How long will it take for the penicillin to help relieve the joint discomfort?" C. "We need to also give these pills to our other children to prevent them from getting rheumatic fever." D. We should give our child the medication after eating."

Correct response: A. "Our child should take the medication until the primary health care provider discontinues it." Explanation: Penicillin is given to children with rheumatic fever to eradicate the hemolytic streptococci that triggered the autoimmune response that causes the disease.Penicillin does not decrease joint pain.Prophylactic use of penicillin with siblings is not indicated.Penicillin should be given on an empty stomach.

When preparing the teaching plan for a client about lithium therapy, the nurse should provide which instruction to the client concerning sodium? Maintain an adequate sodium intake. Discontinue sodium in the diet. Buy foods labeled "low in sodium." Increase sodium in the diet.

Correct response: Maintain an adequate sodium intake. Explanation: The nurse would teach the client taking lithium and his family about the importance of maintaining adequate sodium intake to prevent lithium toxicity. Because lithium is a salt, reduced sodium intake could result in lithium retention with subsequent toxicity. Increasing sodium in the diet is not recommended and may be harmful. Increased sodium levels result in lower lithium levels. Therefore, the drug may not reach therapeutic effectiveness.

Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin? A.Take all the medication until it is gone. B. Notify the health care provider (HCP) if vision changes occur. C. Store gabapentin in the refrigerator. D. Take gabapentin with an antacid to protect against ulcers.

Correct response: Notify the health care provider (HCP) if vision changes occur. Explanation: Gabapentin may impair vision. Changes in vision, concentration, or coordination should be reported to the HCP. Gabapentin should not be stopped abruptly because of the potential for status epilepticus (seizure lasting more than 5 min); this is a medication that must be tapered off. Gabapentin is to be stored at room temperature and out of direct light. It should not be taken with antacids.

Which measure should the nurse include in the care plan for a child who is receiving high-dose methotrexate therapy? Keep the child in a fasting state. Obtain a white blood cell (WBC) count. Prepare for radiography of the spinal canal. Collect a specimen for urinalysis.

Correct response: Obtain a white blood cell (WBC) count. Explanation: Methotrexate is a hemotherapy and Immunosuppressive drug It can treat cancer of the blood, bone, lung, breast, head, and neck. It can also treat rheumatoid arthritis and psoriasis. It is not highly toxic in low doses but may cause severe leukopenia at higher doses. It is customary and recommended for blood tests to be done before therapy to provide a baseline from which to study the effects of the drug on WBC count.Maintaining a fasting state, radiography of the spinal canal, and urinalysis are not necessary when this drug is administered.

Which toxic adverse reaction should the nurse monitor in a toddler taking digoxin? A. weight gain B. tachycardia C. nausea and vomiting D. seizures

Correct response: nausea and vomiting Explanation: Digoxin toxicity in infants and children may present with nausea, vomiting, anorexia, or a slow, irregular heart rate. Weight gain, tachycardia, and seizures are not findings in digoxin toxicity.

When a nurse tries to administer medication, the client refuses it, saying, "I don't have to take those pills if I don't want to." What intervention by the nurse would have the highest priority? A. insisting that the client take the medication because it is specifically ordered for the client B. reporting the client's comments to the physician and the treatment team C. explaining the consequences of not taking the medication, such as a negative outcome D. exploring how the client's feelings affect the decision to refuse medication

D. exploring how the client's feelings affect the decision to refuse medication Explanation: By helping the client explore their feelings about the change in health status, the nurse can determine how these feelings affect the decision to refuse medication. Then the nurse can help the client develop new ways to satisfy self-care, esteem, and other needs and, ultimately, participate fully in the therapeutic regimen. Insisting that the client take the medication, reporting the client's comments to the physician, and explaining the consequences of not taking the medication are inappropriate because these actions do not explore the client's feelings.

meperidine hydrochloride

Schedule II Also called Demerol. A drug used to treat moderate to severe pain. It binds to opioid receptors in the central nervous system. Meperidine hydrochloride is a type of analgesic agent and a type of opioid.

Monoamine Oxidase Inhibitors (MAOIs)

class of antidepressant drugs sometimes used for treating depression Examples: Phenelzine, selegiline, tranylcypromine, isocarboxazid Avoid foods high in tyramine content

Parkinsonism

is characterized by decreased mobility, muscle rigidity, and tremors.

Tardive dyskinesia

is characterized by twitching or involuntary muscular movement.

Dystonia

is characterized by uncoordinated spasmodic movements. Extrapyramidal adverse effects

Whats are the s/sx of an infiltrated IV site?

swelling, pain, hardness, pallor, and coolness of the skin at the site.

When can Tardive dyskinesia usually occur?

usually occurs later in treatment, typically months to years later. A condition affecting the nervous system, often caused by long-term use of some psychiatric drugs. Tardive dyskinesia (TD) is a serious side effect that may occur with certain medications used to treat mental illness. TD may appear as repetitive, jerking movements that occur in the face, neck, and tongue. The symptoms of TD can be very troubling for patients and family members.

A client, hospitalized with heart failure, is receiving digoxin and furosemide intravenously and now has continuous ringing in the ears. What is the appropriate action for the nurse to take at this time? A. Obtain a digoxin level to check for toxicity. B. Note the observation in the medical record and plan to reassess in 2 hours. C. Ask the client about taking aspirin in addition to other medications. Discontinue the furosemide and notify the health care provider (HCP).

Correct response: Discontinue the furosemide and notify the health care provider (HCP). Explanation: The nurse should recognize the ringing in the ears, or tinnitus, as a sign of ototoxicity probably caused by the furosemide. The appropriate action is for the nurse to stop the furosemide and notify the HCP. If the drug is stopped soon enough, permanent hearing loss can be avoided, and the tinnitus should subside. The nurse should note the observation in the medical record but should not delay action. Tinnitus is not a symptom of digoxin toxicity. Aspirin can cause tinnitus, but the nurse should first investigate the obvious cause of tinnitus, which in this case is the furosemide.

The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. What should the nurse do? A. Allow the client to keep the eye drops at the bedside and use as prescribed on the bottle. B. Place the eye drops in the hospital medication drawer and administer as labeled on the bottle. C. Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital. D. Ask the client's wife to assist the client in administering the eye drops while the client is in the hospital.

Correct response: Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital. Explanation: In order to prevent medication errors, clients may not use medications they bring from home; the HCP will prescribe the eye drops as required. It is not safe to place the eye drops in the client's medication box or to permit the client to use them at the bedside. The nurse should ask the wife to take the eye drops home.

A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus? -Gently aspirate the I.V. catheter to check for a blood return. -Insert a second I.V. line into the opposite arm. -Warm the I.V. medication to room temperature. -Place a tourniquet on the arm in which the injection will be administered.

Correct response: Gently aspirate the I.V. catheter to check for a blood return. Explanation: Before administering an I.V. bolus, the nurse should gently aspirate the I.V. catheter for a small amount of blood to ensure correct placement of the I.V. catheter. Then the nurse may inject the medication over the recommended time interval. The nurse doesn't need to insert another I.V. line unless the ordered medication is incompatible with the medication in the I.V. solution. Warming the medication could alter the drug's action. Placing a tourniquet on the arm would close off the venous system and prevent drug injection.

Which technique is correct when administering a subcutaneous injection? A. Use a 1-inch (2.5-cm) needle for injection. B. Insert the needle at a 45-degree angle to the skin. C. Spread the skin tightly at the injection site. D. Draw 0.2 ml of air into the syringe before administration.

Correct response: Insert the needle at a 45-degree angle to the skin. Explanation: Subcutaneous injections are administered at an angle of 45 to 90 degrees, depending on the size of the client. Subcutaneous needles are typically to 1/2 to 5/8 inches (1.3 to 1.6 cm) in length. The skin should be pinched up at the injection site to elevate the subcutaneous tissue. Air is not drawn into the syringe for a subcutaneous injection.

The nurse observes a new parent give an oral medication to a 4-month-old infant. The parent instills the medication directly in the back of the infant's throat. Which choice is the nurse's best action? A. Instruct the parent to instill a small amount of the medication inside the baby's cheek. B. Praise the parent's technique of giving the medication. C. Have the parent lay the infant flat, restraining the arms, while giving the medication. D. Demonstrate to the parent ways to prop the infant in a sitting position for medication administration.

Correct response: Instruct the parent to instill a small amount of the medication inside the baby's cheek. Explanation: The parent's technique of instilling the medication in the back of the throat is not correct and could cause the infant to choke. The nurse should instruct the parent to instill a small amount at a time inside the infant's cheek. The parent should hold an infant in the bottle-feeding position when administering an oral medication by placing the child's inner arm behind the back, supporting the head in the crook of the elbow, and holding the child's free hand with the hand of the supporting arm. Propping a 4-month-old infant is not appropriate. The infant cannot sit unsupported even in a seated position. Administering medication to an infant lying flat could cause choking and aspiration.

What information should the nurse provide to the client who is receiving warfarin? A. Partial thromboplastin time values determine the dosage of warfarin sodium. B. Protamine sulfate is used to reverse the effects of warfarin sodium. C. International Normalized Ratio (INR) is used to assess effectiveness. D. Warfarin sodium will facilitate clotting of the blood.

Correct response: International Normalized Ratio (INR) is used to assess effectiveness. Explanation: INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots.

The nurse will assist with the sedation procedure for a client who is undergoing an ankle reduction. Which medication should the nurse prepare? Ketamine Glyburide Rocuronium Succinylcholine

Correct response: Ketamine Explanation: Ketamine is a common medication used for procedures that require moderate sedation, such as an ankle reduction. Glyburide is a sulfonylurea hypoglycemic oral medication used for treating diabetes. Rocuronium and succinylcholine are neuromuscular blocking agents and would not be used in moderate sedation; they cause paralysis and the client would become apneic, requiring immediate airway management.

A client presents with severe headache, blurred vision, anxiety and confusion. The client's blood pressure is 224/137 mm Hg. The family reports that the client has hypertension, but has not been taking the prescribed blood pressure medications. The nurse anticipates giving which medication? Norepinephrine Amiodarone Methotrexate Labetalol

Correct response: Labetalol Explanation: This client is showing signs and symptoms of a hypertensive crisis, or hypertensive emergency, and the nurse should anticipate treatment/medications to lower the blood pressure. Labetalol is a beta-blocker medication given intravenously that is often a first-line treatment for hypertensive crisis. Norepinephrine is not indicated for this client as it is a vasopressor and increases blood pressure. Amiodarone is given for cardiac arrythmias and would not help lower blood pressure. Methotrexate is an antineoplastic medication used for treating various cancers and severe rheumatoid arthritis.

A nurse is administering dexamethasone 4 mg I.V. to a client diagnosed with a brain tumor. The nursing assistant informs the nurse that the client's fingerstick glucose level is 240 mg/dl (13.32 mmol/L). A sliding insulin scale hasn't been ordered. How should the nurse intervene? A. Administer dexamethasone as ordered and inform the physician when the physician makes rounds. B. Administer dexamethasone as ordered and not be concerned about the fingerstick glucose level because it's common with steroid therapy. C. Notify the physician of the fingerstick glucose level, inquire about insulin therapy, and ask whether the dexamethasone should be administered. D. Administer the dexamethasone because the client has no history of diabetes.

Correct response: Notify the physician of the fingerstick glucose level, inquire about insulin therapy, and ask whether the dexamethasone should be administered. Explanation: Dexamethasone is commonly ordered to help reduce edema caused by brain tumors. Elevation in glucose level is a common adverse reaction to the drug. The nurse should notify the physician of the elevated fingerstick glucose level and ask about insulin therapy and whether the drug should be administered. The nurse shouldn't wait until the physician makes rounds to report the elevated glucose level; a delay in treatment could cause further elevation in the glucose level. The glucose level should be treated despite the client's past medical history.

While reviewing a client's chart, the nurse notices that the client has myasthenia gravis. Which statement about neuromuscular blocking agents is true for a client with this condition? A. The client may be less sensitive to the effects of a neuromuscular blocking agent. B. Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage. C. Pancuronium shouldn't be used; succinylcholine may be used in a lower dosage. D. Pancuronium and succinylcholine both require cautious administration.

Correct response: Pancuronium and succinylcholine both require cautious administration. Explanation: The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis because of the potential for prolonged recovery times. Such a client isn't less sensitive to the effects of a neuromuscular blocking agent. Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with myasthenia gravis.

The nurse is assessing for blood return from a client's implanted port. Which nursing intervention is appropriate to assure that the needle will be flushed with pure saline? Wash hands before and after the procedure. Draw the smallest amount of blood required for the sample. Prevent blood from entering the saline flush syringe. Flush with heparin after drawing the sample.

Correct response: Prevent blood from entering the saline flush syringe. Explanation: To assure that the needle will be flushed with pure saline, the nurse does not allow blood to enter the saline flush syringe when assessing for blood return from an implanted port. Washing hands prevents contamination, drawing the least amount of blood prevents overwasting, and flushing with heparin prevents clots.

Which action is a priority for the nurse when finding medications at a client's bedside? A. Leave the medications, as the client will take them after the next meal. B. Leave the medications and seek the nurse who left them in the room. C. Remove the medications from the room and discard them into an appropriate disposal bin. D. Label the medications and place them back in the medication room.

Correct response: Remove the medications from the room and discard them into an appropriate disposal bin. Explanation: Disposing of the medications in the appropriate manner reflects best practice of nursing and medication administration. Leaving the medications by the client's bed would create a risk for another client to take them, for this client to take them inappropriately, or for them to get lost. It would be incorrect and unsafe to label medications that were taken out by another nurse.

The client was found not breathing and was transported to the hospital. A family member states the client may have taken too much pain medication because the client frequently forgets if the medication was taken. Which observation(s) by the nurse indicates therapeutic effect of naloxone hydrochloride in the client? Select all that apply. Reverses decreased respiratory rate of 10. Reverses decreased level of consciousness. Increases nerve pain. Reverses blood pressure of 90/58. Increases inflammation.

Correct response: Reverses decreased respiratory rate of 10. Reverses decreased level of consciousness. Reverses blood pressure of 90/58. Explanation: Therapeutic effect includes reversal of respiratory depression, sedation, and hypotension. Therapeutic effect does not include increasing nerve pain or increasing inflammation.

The client with idiopathic thrombocytopenic purpura (ITP) asks the nurse why it is necessary to take steroids. The nurse should base the response on which information? A. Steroids destroy the antibodies and prolong the life of platelets. B. Steroids neutralize the antigens and prolong the life of platelets. C. Steroids increase phagocytosis and increase the life of platelets. D. Steroids alter the spleen's recognition of platelets and increase the life of platelets.

Correct response: Steroids alter the spleen's recognition of platelets and increase the life of platelets. Explanation: ITP is treated with steroids to suppress the splenic macrophages from phagocytizing the antibody-coated platelets, which are recognized as foreign bodies, so that the platelets live longer. The steroids also suppress the binding of the autoimmune antibody to the platelet surface. Steroids do not destroy the antibodies on the platelets, neutralize antigens, or increase phagocytosis.

Which principle should a nurse consider when administering pain medication to a client? A. Use opioid combination drugs or nonopioid analgesics only for severe pain. B. I.V. pain medications may take as long as 2 hours to relieve pain. C. Sustained-release oral formulations should be given around the clock, if possible, for control of chronic pain. D. Morphine and hydromorphone shouldn't be used to treat severe pain.

Correct response: Sustained-release oral formulations should be given around the clock, if possible, for control of chronic pain. Explanation: Administering sustained-release oral formulations around the clock provides better relief of chronic pain by keeping blood levels within therapeutic range. Opioid combination drugs and nonopioid medications are most effective in the treatment of mild to moderate pain. I.V. medications usually act within 1 hour of administration. Morphine and hydromorphone are drugs of choice for severe pain.

A client is 2 days post small bowel resection with a placement of an ostomy in the right lower quadrant. The nurse is teaching the client to apply an ostomy appliance to the client's abdomen. Which client action would indicate to the nurse that the teaching was successful? A. The client trims the faceplate opening giving the stoma a 1-inch (2.5 cm) border around the stoma. B. The client assesses the stoma and the surrounding skin before placing the new appliance. C. The client chooses an antibacterial soap to scrub the fecal material around the stoma. D. The client states that the faceplate should be changed every other day.

Correct response: The client assesses the stoma and the surrounding skin before placing the new appliance. Explanation: For a client with an ostomy, maintaining skin integrity is a priority. The client should inspect the area with each appliance change for skin integrity issues. The client should gently wash the area surrounding the stoma using a facecloth and mild soap. Scrubbing the area around the stoma can damage the skin and cause bleeding. The faceplate opening should be no more than 1/8 inch (.3175 cm) to 1/6 inch (.4233 cm) larger than the stoma. This size protects the skin from exposure to irritating fecal material. The client should change the appliance every 3 to 7 days. It is important to create an adequate seal and prevent leakage of fecal material from under the faceplate by applying a thin layer of skin barrier and smoothing out wrinkles in the faceplate.

A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for: Vertigo. Facial paralysis. Impaired vision. Difficulty swallowing.

Correct response: Vertigo. Explanation: The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for hearing and equilibrium. Streptomycin can damage this nerve (ototoxicity). Symptoms of ototoxicity include vertigo, tinnitus, hearing loss, and ataxia. Facial paralysis would result from damage to the facial nerve (VII). Impaired vision would result from damage to the optic (II), oculomotor (III), or the trochlear (IV) nerves. Difficulty swallowing would result from damage to the glossopharyngeal (IX) or the vagus (X) nerve.

The nurse should advise which client who is taking lithium to consult with the health care provider regarding a potential adjustment in lithium dosage? a client who continues work as a computer programmer a client who attends college classes a client who can now care for her children a client who is beginning training for a tennis team

Correct response: a client who is beginning training for a tennis team Explanation: A client who is beginning training for a tennis team would most likely require an adjustment in lithium dosage because excessive sweating can increase the serum lithium level, possibly leading to toxicity. Adjustments in lithium dosage would also be necessary when other medications have been added, when an illness with high fever occurs, and when a new diet begins.

The postoperative nursing assessment of a client's ability to swallow fluids before providing oral fluids is based on the type of anesthesia given. Which client would not have delayed fluid restrictions? The client who had: A. undergone a bronchoscopy under local anesthesia. B. a transurethral resection of a bladder tumor under general anesthesia. C. a repair of carpal tunnel syndrome under local anesthesia. D. an inguinal herniorrhaphy with spinal and intravenous conscious sedation.

Correct response: a repair of carpal tunnel syndrome under local anesthesia. Explanation: The client who has not had the gag reflex anesthetized is the client who had a repair of the carpal tunnel syndrome under local anesthesia because the area being anesthetized was the tissue in the wrist. The client who had a bronchoscopy received a local anesthetic on the vocal cords, and the nurse should check the gag reflex or ability to swallow before administering fluids. Clients who had general anesthesia or intravenous conscious sedation received medication for central nervous system sedation, and the nurse should assess the level of consciousness and ability to swallow before administering fluids.

A client is prescribed adenosine for treatment of supraventricular tachycardia (SVT). When should the nurse assess the client for a response to the dose of adenosine? after 15 to 20 minutes after 1 to 2 minutes after 30 minutes after 5 to 10 minutes

Correct response: after 1 to 2 minutes Explanation: Adenosine is the first-line medication for SVT, and can convert the heart rhythm to a normal rate and rhythm. It is given as an emergent medication and should be delivered as rapid intravenous (IV) bolus over 1 to 2 seconds. It should be administered at the peripheral IV site that is closest to the client's core. Once administered, the IV site should be flushed with 20 ml of normal saline immediately. The client's response is known within 1 to 2 minutes of administration, at which time the cardiac rhythm will dictate if the dose needs to be repeated. Waiting longer than 2 minutes to assess the response would delay potentially life-saving treatment.

A client is taking clozapine and complains of a sore throat. This symptom may be an indication of which adverse reaction? extrapyramidal reaction tardive dyskinesia Reye's syndrome agranulocytosis

Correct response: agranulocytosis Explanation: clozapine... It can treat schizophrenia. It can also lower the risk of suicidal behavior in patients with schizophrenia or schizoaffective disorder. The complaint of a sore throat may indicate an infection caused by agranulocytosis, a depletion of white blood cells. Although extrapyramidal reaction and tardive dyskinesia may occur, a sore throat isn't an indication of these conditions. Reye's syndrome is caused by a virus unrelated to clozapine.

After 3 days of taking haloperidol , the client shows an inability to sit still, is restless and fidgety, and paces around the unit. The client is showing signs of which extrapyramidal adverse reactions? dystonia akathisia parkinsonism tardive dyskinesia

Correct response: akathisia Explanation: The client's behavior is best defined as akathisia, or motor restlessness, and a compulsion to move constantly.Dystonia is characterized by uncoordinated spasmodic movements.Parkinsonism is characterized by decreased mobility, muscle rigidity, and tremors.Tardive dyskinesia is characterized by twitching or involuntary muscular movement.

A nurse is caring for a 3-year-old child admitted to the pediatric unit with acetaminophen poisoning. The nurse administers acetylcysteine every 4 hours for 72 hours. Which laboratory findings confirm the effectiveness of the drug therapy? alanine aminotransferase and aspartate aminotransferase creatine kinase-MB blood urea nitrogen and serum creatinine complete blood count

Correct response: alanine aminotransferase and aspartate aminotransferase Explanation: Acetaminophen poisoning causes liver damage, raising the liver enzymes alanine aminotransferase and aspartate aminotransferase. Creatine kinase-MB levels are elevated with heart muscle damage and aren't associated with acetaminophen poisoning. Blood urea nitrogen and serum creatinine levels provide information on renal function and aren't indicators of effectiveness of drug therapy in acetaminophen poisoning. A complete blood count won't give the nurse information on the effectiveness of therapy.

A client with renal insufficiency is admitted to the hospital with pneumonia. The client is being treated with gentamicin. Which laboratory value should be closely monitored? blood urea nitrogen (BUN) sodium level alkaline phosphatase white blood cell (WBC) count

Correct response: blood urea nitrogen (BUN) Explanation: BUN and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity. Sodium level should be routinely monitored in all hospitalized clients. Alkaline phosphatase helps evaluate liver function. The WBC count should be monitored to evaluate the effectiveness of the antibiotic; it doesn't help evaluate kidney function.

A toddler with a ventricular septal defect is receiving digoxin to treat heart failure. Which assessment finding should be the nurse's priority concern? bradycardia tachycardia hypertension hyperactivity

Correct response: bradycardia Explanation: Digoxin enhances cardiac efficiency by increasing the force of contraction and decreasing the heart rate. An early sign of digoxin toxicity is bradycardia (an abnormally slow heart rate). To help detect digoxin toxicity, the nurse always should measure the apical heart rate before administering each digoxin dose. Other signs and symptoms of digoxin toxicity include arrhythmias, vomiting, hypotension, fatigue, drowsiness, and visual halos around objects. Tachycardia, hypertension, and hyperactivity aren't associated with digoxin toxicity.

Which foods are contraindicated for a client taking tranylcypromine? whole grain cereals and bagels chicken livers, Chianti wine, and beer oranges and vodka chicken, rice, and apples

Correct response: chicken livers, Chianti wine, and beer Explanation: A client taking a monoamine oxidase inhibitor antidepressant such as tranylcypromine shouldn't eat foods containing tyramine. Such foods include chicken livers, Chianti wine, beer, ale, aged game meats, broad beans, aged cheeses, sour cream, avocados, yogurt, pickled herring, yeast extract, chocolate, excessive caffeine, vanilla, and soy sauce. The client also must refrain from taking cold and hay fever preparations that contain vasoconstrictive agents.

The nurse observes the client instill eye drops. The client says, "I just try to hit the middle of my eyeball so the drops do not run out of my eye." What should the nurse tell the client about this method of instilling eye drops? This method may cause: scleral staining. corneal injury. excessive lacrimation. systemic drug absorption.

Correct response: corneal injury. Explanation: The cornea is sensitive and can be injured by eye drops falling onto it. Therefore, eye drops should be instilled into the lower conjunctival sac of the eye to avoid the risk of corneal damage. The drops do not cause scleral staining or excessive lacrimation. Systemic absorption occurs when eye drops enter the tear ducts.

The client is receiving an IV infusion of 5% dextrose in normal saline running at 125 ml/h. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first: discontinue the infusion. apply a warm soak to the site. stop the flow of solution temporarily. irrigate the needle with normal saline.

Correct response: discontinue the infusion. Explanation: Signs of infiltration include slowing of the infusion and swelling, pain, hardness, pallor, and coolness of the skin at the site. If these signs occur, the IV line should be discontinued and restarted at another infusion site. The new anatomic site, time, and type of cannula used should be documented. The nurse may apply a warm soak to the site, but only after the IV line is discontinued. Parenteral administration of fluids should not be stopped intermittently. Stopping the flow does not treat the problem, nor does it address the client's needs for fluid replacement. Infiltrated IV sites should not be irrigated; doing so will only cause more swelling and pain.

A depressed client has been taking a selective serotonin reuptake inhibitor (SSRI) in the evening, and is upset because he cannot perform sexually due to erectile problems. What is the nurse's best response? A. stop taking the drug and notify the prescriber B. engage in sexual activity prior to taking the drug C. monitor for low blood pressure on a daily basis D. take the drug with food or 8 oz of water

Correct response: engage in sexual activity prior to taking the drug Explanation: A viable option is for the client to engage in sexual activity before taking his daily antidepressant medication. It is not appropriate to suggest stopping the medication. Monitoring the client's blood pressure and taking the drug with food or 8 oz of water will not address the erectile dysfunction experienced by the client.

The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site has which appearance? minimal leaking no swelling tissue pallor evidence of a bleb

Correct response: evidence of a bleb Explanation: A properly administered intradermal injection shows evidence of a bleb at the injection site. There should be no leaking of medication from the bleb; it needs to be absorbed into the tissue. Lack of swelling at the injection site means that the injection was given too deeply. The presence of tissue pallor does not indicate that the injection was given correctly.

A client has a maintenance lithium level of 0.8 mmol/L. The nurse should assess the client for which manifestations? A. signs and symptoms of lithium toxicity B. manifestations of acute mania C. sufficient sodium intake D. fairly good control of mania symptoms

Correct response: fairly good control of mania symptoms Explanation: Maintenance serum levels between 0.8 and 1.2 are considered appropriate and therapeutic. The nurse would expect the client to have fairly well controlled symptoms. Signs and symptoms of lithium toxicity would include a serum lithium level greater than 1.5. Manifestations of acute mania would suggest nontherapeutic serum levels of lithium. If the lithium level was high it would be appropriate to determine in the client is taking sufficient sodium, but the client has a therapeutic level.

A client is prescribed clonidine to treat alcohol withdrawal. Which assessment data will the nurse monitor for? hypotension polyuria numbness and tingling tremors

Correct response: hypotension Explanation: clonidine- used to tx high BP Clonidine is used as adjunctive therapy in opioid withdrawal. It is mainly used for the treatment of blood pressure, however. With treatment for alcohol withdrawal, a priority assessment should be for hypotension. Polyuria, numbness and tingling, and tremors are not common side effects of clonidine.

When teaching an adolescent with a seizure disorder who is receiving valproic acid, the nurse should instruct the client to immediately report which sign or symptom to the health care provider (HCP)? diarrhea loss of appetite jaundice sore throat

Correct response: jaundice Explanation: A toxic effect of valproic acid is liver toxicity, which may manifest with jaundice and abdominal pain. If jaundice occurs, the client needs to notify the HCP as soon as possible. Diarrhea and sore throat are not common side effects of this drug. Increased appetite is common with this drug.

The client has second- and third-degree burns. The family asks if there is anything that can be given to the client for pain. Which analgesic would the nurse anticipate to manage the client's pain? A. heparin administered by IV B. meperidine administered by IM C. codeine administered by PO D. morphine administered by IV

Correct response: morphine administered by IV Explanation: The best and most effective medication for second- and third-degree burns would be IV morphine. IM medications may not be absorbed, and codeine may not provide sufficient analgesia.

An outpatient client who has been receiving haloperidol for two days develops muscular rigidity, altered consciousness, a temperature of 103° F (39.4° C), and trouble breathing on day 3. The nurse interprets these findings as indicating which complication? neuroleptic malignant syndrome tardive dyskinesia extrapyramidal adverse effects drug-induced parkinsonism

Correct response: neuroleptic malignant syndrome Explanation: The client is exhibiting hallmark signs and symptoms of life-threatening neuroleptic malignant syndrome induced by the haloperidol. Tardive dyskinesia usually occurs later in treatment, typically months to years later. Extrapyramidal adverse effects (dystonia, akathisia) and drug-induced parkinsonism, although common, are not life threatening.

Gentamicin IV has been prescribed to treat a client's infection. The nurse should monitor the client for: ascites. confusion. ototoxicity. cardiac arrhythmias.

Correct response: ototoxicity. Explanation: Ototoxicity is a serious side effect of gentamicin. Tinnitus and dizziness are common; irreversible deafness can develop if the onset of ototoxicity is not detected early. Gentamicin is also known to be nephrotoxic and hepatotoxic.Ascites, arrhythmias, and confusion are not common side effects.

A client with major depressive disorder is receiving phenelzine. The nurse intervenes when the client orders which food for lunch? pepperoni pizza yogurt with fruit Salisbury steak green beans

Correct response: pepperoni pizza Explanation: Clients taking phenelzine, a monoamine oxidase inhibitor, cannot take foods with high tyramine content. Pepperoni is a sausage with a high tyramine content. Yogurt with fruit, Salisbury steak, and green beans have little or no tyramine.

A client has been receiving total parenteral nutrition (TPN) for the last 5 days. Before discontinuing the infusion, the infusion rate is slowed. What complication of TPN infusion should the nurse assess the client for as the infusion is discontinued? essential fatty acid deficiency dehydration rebound hypoglycemia malnutrition

Correct response: rebound hypoglycemia Explanation: When dextrose is abruptly discontinued, rebound hypoglycemia can occur. The nurse should assess the client for symptoms of hypoglycemia. Essential fatty acid deficiency is very unlikely to occur because some of these fatty acids are stored. Preventing dehydration or malnutrition is not the reason for tapering the infusion rate; the client's hydration and nutritional status and ability to maintain adequate intake must be established before TPN is discontinued.

Which is most critical for the nurse to communicate to the health care provider (HCP) prior to placing an epidural analgesia catheter? The client: consumed 240 mL of beef broth 4 hours prior. has had an indwelling urinary catheter in place for 2 days. received enoxaparin 40 mg subcutaneously 1 hour ago. has an albumin level of 3.5 g/dL.

Correct response: received enoxaparin 40 mg subcutaneously 1 hour ago. Explanation: Clients receiving anticoagulation are at high risk for an epidermal hematoma (when blood accumulates between the skull and the dura mater). If the client is taking any anticoagulants, this should be immediately relayed to the HCP scheduled to perform the procedure. Clear liquids may be limited 2 hours prior to the procedure, but this varies by HCP and institutional guidelines. The albumen level is on the lower end of normal and is not a concern. The indwelling urinary catheter is not a concern at this time.

A client is being given naltrexone as part of an alcohol treatment program. When the client asks the nurse to explain the intended effects of the drug, the nurse should state that the drug: prevents withdrawal symptoms. reduces compulsions to drink. treats peripheral neuropathy. manages symptoms of anxiety.

Correct response: reduces compulsions to drink. Explanation: The mechanism of action of naltrexone isn't fully understood. The drug blocks opiate receptors and is believed to help diminish the compulsion to drink. Naltrexone doesn't prevent withdrawal symptoms, treat peripheral neuropathy, or manage symptoms of anxiety.

When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the client's: physical needs. safety needs. psychosocial needs. medical needs.

Correct response: safety needs. Explanation: The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as those of the staff. Drug effects are unpredictable and prolonged, and the client may easily become aggressive and physically violent. After safety needs have been met, the client's physical, psychosocial, and medical needs may be addressed.

A client with a positive Mantoux test result is taking isoniazid (INH) and rifampin (RIF) for treatment of tuberculosis. In the nursing assessment, the nurse should assess specifically for which finding during the clinic visit? sclera peripheral edema dyspnea pruritus

Correct response: sclera Explanation: Clients taking isoniazid may show signs of hepatic stress. The nurse should assess for signs of liver dysfunction. Although if jaundice is present a client would potentially have pruritus, the early sign is sclera yellowing.

When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which laboratory value? serum sodium serum potassium serum creatinine serum calcium

Correct response: serum creatinine Explanation: It is essential to monitor serum creatinine in the client receiving an aminoglycoside antibiotic because of the potential of this type of drug to cause acute tubular necrosis. Aminoglycoside antibiotics do not affect serum sodium, potassium, or calcium levels.

x A client has a history of schizophrenia. Because of a history of noncompliance with antipsychotic therapy, the client will receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in the teaching plan? A. asking the physician for droperidol to control any extrapyramidal symptoms that occur B. sitting up for a few minutes before standing to minimize orthostatic hypotension C. notifying the physician if the client's thoughts do not normalize within 1 week D. expecting transient symptoms of tardive dyskinesia to occur

Correct response: sitting up for a few minutes before standing to minimize orthostatic hypotension Explanation: The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. Antipsychotic effects of the drug may not become evident for several weeks. Droperidol increases the risk of extrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately.

The nurse is teaching a client and family about phenelzine. Which food should the nurse instruct the client to avoid? eggs chicken peanut butter sour cream

Correct response: sour cream Explanation: Because phenelzine is a monoamine oxidase inhibitor, the client should avoid foods high in tyramine to prevent the development of hypertensive crisis. Foods and beverages high in tyramine include sour cream, aged cheeses, yogurt, red wine, beer, bananas, avocados, salami, sausage, bologna, caffeinated coffee and colas, and chocolate. High-protein foods that have undergone protein breakdown by aging, fermentation, pickling, or smoking should be avoided. Hypertensive crisis, evidenced by occipital headache, stiff neck, nausea and vomiting, sweating, nosebleed, dilated pupils, tachycardia, and constricting chest pain, can occur with this food-drug combination.Eggs, chicken, and peanut butter are not foods high in tyramine and can be included in the client's diet.

When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands: A. results of treatment are rapid and dramatic but may not last. B. although uncomfortable, this reaction isn't serious. C. the client shouldn't buy drugs on the street. D. the client must take benztropine as ordered to prevent a return of symptoms.

Correct response: the client must take benztropine as ordered to prevent a return of symptoms. Explanation: An oral anticholinergic agent such as benztropine is commonly ordered to control and prevent the return of symptoms. Dystonic reactions are typically acute and reversible. Dystonic reactions can be life-threatening when airway patency is compromised. Lecturing the client about buying drugs on the street isn't appropriate.

A client is taking vancomycin. The nurse should report which possible side effect to the health care provider? vertigo tinnitus muscle stiffness ataxia

Correct response: tinnitus Explanation: The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated with vancomycin.

The nurse is preparing a teaching plan about increased exercise for a female client who is receiving long-term corticosteroid therapy. What type of exercise is most appropriate for this client? floor exercises stretching running walking

Correct response: walking Explanation: The best exercise for females who are on long-term corticosteroid therapy is a low-impact, weightbearing exercise such as walking or weight lifting. Floor exercises do not provide for the weightbearing. Stretching is appropriate but does not offer sufficient weightbearing. Running provides for weightbearing but is hard on the joints and may cause bleeding.

The nurse is caring for a client with an I.V. line. During care of the I.V. line, the nurse would be required to wear protective gloves in which situations? Select all that apply. when inserting the I.V. When discontinuing the I.V. When changing the I.V. site When spiking a new I.V. bag When priming the I.V. tubing

Correct response: when inserting the I.V. When discontinuing the I.V. When changing the I.V. site Explanation: The nurse should wear protective gloves when inserting the I.V., when discontinuing the I.V., and when changing the I.V. site due to the risk of exposure to blood and bodily fluids. The nurse would not be required to wear protective gloves while spiking or hanging a new bag of solution.

Tetany & tremors are related to what electrolyte imbalance?

Hypocalcemia

isoniazid

Ther. Class.antituberculars Indication: First-line therapy of active tuberculosis, in combination with other agents. Prevention of tuberculosis in patients exposed to active disease (alone). Pt teaching: Advise patient to notify health care professional promptly if signs and symptoms of hepatitis (yellow eyes and skin, nausea, vomiting, anorexia, dark urine, unusual tiredness, or weakness) or peripheral neuritis (numbness, tingling, paresthesia) occur. Pyridoxine (B6) may be used concurrently to prevent neuropathy or to treat overdose -Avoid use of alcohol

rifampin (RIF)

Ther. Class.antituberculars Indications Active tuberculosis (with other agents). Elimination of meningococcal carriers. Inform patients taking rifampin that saliva, sputum, sweat, tears, urine, and feces may become red-orange to red-brown and that soft contact lenses may become permanently discolored. Patient/Family Teaching Advise patient to take medication once daily (unless biweekly regimens are used), as directed, and not to skip doses or double up on missed doses. Emphasize the importance of continuing therapy even after symptoms have subsided. Length of therapy for tuberculosis depends on regimen being used and underlying disease states. Patients on short-term prophylactic therapy should also be advised of the importance of compliance with therapy. Advise patient to notify health care professional promptly if signs and symptoms of hepatitis (yellow eyes and skin, nausea, vomiting, anorexia, unusual tiredness, weakness) or of thrombocytopenia (unusual bleeding or bruising) occur. Caution patient to avoid the use of alcohol during this therapy, because this may increase the risk of hepatotoxicity. Instruct patient to report the occurrence of flu-like symptoms (fever, chills, myalgia, headache) promptly. Rifampin may occasionally cause drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Inform patient that saliva, sputum, teeth, sweat, tears, urine, and feces may become red-orange to red-brown and that soft contact lenses may become permanently discolored. Advise patient that this medication has teratogenic properties and may decrease the effectiveness of oral contraceptives. Counsel females of reproductive potential to use a nonhormonal form of contraception throughout therapy. Emphasize the importance of regular follow-up exams to monitor progress and to check for side effects.

How does salt impact lithium?

While taking lithium, do not make sudden changes to your salt intake. A sudden decrease in sodium intake (a component of salt) may result in higher serum lithium levels, while a sudden increase in sodium might prompt your lithium levels to fall.

The client who does not respond adequately to fluid replacement has a prescription for an IV infusion of dopamine hydrochloride at 5 mcg/kg/min. To determine that the drug is having the desired effect, the nurse should assess the client for: 1. Increased renal and mesenteric blood fow. 2. Increased cardiac output. 3. Vasoconstriction. 4. Reduced preload and afterload.

2. Increased cardiac output. At medium doses (4 to 8 mcg/kg/min), dopamine hydrochloride slightly increases the heart rate and improves contractility to increase cardiac output and improve tissue perfusion. When given at low doses (0.5 to 3.0 mcg/kg/min), dopamine increases renal and mesenteric blood flow. At high doses (8 to 10 mcg/kg/min), dopamine produces vasoconstriction, which is an undesirable effect. Dopamine is not given to affect preload and afterload.

A client is receiving dopamine hydrochloride for treatment of shock. The nurse should: 1. Administer pain medication concurrently. 2. Monitor blood pressure continuously. 3. Evaluate arterial blood gases at least every 2 hours. 4. Monitor for signs of infection.

2. Monitor blood pressure continuously. The client who is receiving dopamine hydrochloride requires continuous blood pressure monitoring with an invasive or noninvasive device. The nurse may titrate the IV infusion to maintain a systolic blood pressure of 90 mm Hg. Administration of a pain medication concurrently with dopamine hydrochloride, which is a potent sympathomimetic with dose-related alpha-adrener-gic agonist, beta 1-selective adrenergic agonist, and dopaminergic blocking effects, is not an essential nursing action for a client who is in shock with already low hemodynamic values. Arterial blood gas concentrations should be monitored according to the client's respiratory status and acid-base balance status and are not directly related to the dopamine hydrochloride dosage. Monitoring for signs of infection is not related to the nursing action for the client receiving dopamine hydrochloride.

Subcutaneous injections are administered at what angle?

45-90 degrees

What therapeutic class is enoxaparin?

Anticoagulant

The health care provider (HCP) changes a client's current dose of IM meperidine hydrochloride to an oral dosage. The current IM dosage is 75 mg every 4 hours as needed. What dosage of oral meperidine will be required to provide an equivalent analgesic dose? 25 to 50 mg every 4 hours 75 to 100 mg every 4 hours 125 to 140 mg every 4 hours 150 to 300 mg every 4 hours

Correct response: 150 to 300 mg every 4 hours Explanation: The equianalgesic dose of oral meperidine hydrochloride is up to four times the IM dose. Meperidine hydrochloride can be given orally, but it is much more effective when given IM.

The client tells the nurse that they frequently experiences nausea and vomiting after receiving radiation and chemotherapy. The nurse adapts the plan of care to include antiemetics. What is the most appropriate time for the administration of the medication? A. 30 minutes before therapy begins B. at the same time as therapy C. immediately after nausea begins D. when therapy is completed

Correct response: 30 minutes before therapy begins Explanation: Antiemetics are most beneficial if given before the onset of nausea and vomiting. To calculate the optimum time for administration, the first dose is given 30 minutes to 1 hour before nausea is expected, and then every two, four, or six hours for approximately 24 hours after chemotherapy. If the antiemetic was given with the medication, or after the medication, it could lose its maximum effectiveness when needed.

A nurse administered neutral protamine Hagedorn (NPH) insulin to a client with diabetes mellitus at 7 a.m. (0700). At what time should the nurse expect the client to be most at risk for hypoglycemia? 10 a.m. (1000) noon (1200) 4 p.m. (1600) 10 p.m. (2200)

Correct response: 4 p.m. (1600) Explanation: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m. (0700), the client is at greatest risk for hypoglycemia from 3 p.m. (1500) to 7 p.m. (1900).

A nurse is providing teaching to an adolescent who has been prescribed phenytoin for seizures. What information should the nurse include in this teaching? Select all that apply. A. "Brush your teeth using a soft toothbrush." B. "You can stop taking this medication when your seizures stop." C. "A rash is normal while taking this medication." D. "You will need to have bloodwork done frequently." E. "You should wear an ID bracelet indicating you are taking this drug."

Correct response: A. "Brush your teeth using a soft toothbrush." D. "You will need to have bloodwork done frequently." E. "You should wear an ID bracelet indicating you are taking this drug." Explanation: This drug can cause gingival hyperplasia, so proper dental care is important to prevent infection. This drug has a narrow therapeutic index and many drug interactions. A steady serum level is needed to maintain effectiveness without toxicity, so serum levels should be done frequently. An ID bracelet is necessary because of the numerous drug interactions. This drug should not be stopped abruptly as this may precipitate seizures. A measles-like rash may lead to Steven-Johnson syndrome. If this rash occurs, the drug should not be used.

A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply. A. Administer Diphenhydramine. B. Insert an intravenous line. C. Give metoprolol. D. Have respiratory therapy provide an albuterol treatment. E. Monitor international normalized ratio (INR) level.

Correct response: A. Administer Diphenhydramine. B. Insert an intravenous line. D. Have respiratory therapy provide an albuterol treatment. Explanation: Administering diphenhydramine reverses the effect of histamine. Inserting an intravenous line will allow access to administer medications quickly. Metoprolol is a medication used to treat hypertension or chest pain. Administering an albuterol treatment reverses histamine-induced bronchospasm. The international normalized ratio (INR) level is monitored for warfarin treatment.

A nurse is preparing a teaching plan for a client who was prescribed enalapril maleate for the treatment of hypertension. Which instructions would the nurse include in the teaching plan? Select all that apply. A. Instruct the client to avoid salt substitutes. B. Tell the client that light-headedness is a common adverse effect that does not need to be reported. C. Inform the client of a potential sore throat for the first few days of therapy. D. Advise the client to report facial swelling or difficulty breathing immediately. E. Tell the client that blood tests will be necessary every 3 weeks for 2 months and periodically after that. F. Advise the client not to change the position suddenly to minimize the risk of orthostatic hypotension.

Correct response: A. Instruct the client to avoid salt substitutes. D. Advise the client to report facial swelling or difficulty breathing immediately. F. Advise the client not to change the position suddenly to minimize the risk of orthostatic hypotension. Explanation: The nurse would tell the client to avoid salt substitutes because they may contain potassium, which can cause light-headedness and syncope. Facial swelling or difficulty breathing would be reported immediately because they may be signs of angioedema, which would require discontinuation of the drug. The client would also be advised to change positions slowly to minimize the risk of orthostatic hypotension. The nurse would tell the client to report light-headedness, especially during the first few days of therapy, so dosage adjustments can be made. The client would also report signs of infection, such as sore throat and fever, because the drug may decrease the white blood cell (WBC) count. Because this effect is generally seen within 3 months, the WBC count and differential should be monitored periodically.

The nurse received an order to administer intravenous fluids with potassium for a client receiving intravenous fluids. What step(s) are included in the process? Select all that apply. A. Review the client's laboratory values. B. Obtain correct ordered intravenous fluids. C. Identify client with two methods. D. Assist the client with ambulation. E. Review the label of the intravenous tubing.

Correct response: A. Review the client's laboratory values. B. Obtain correct ordered intravenous fluids. C. Identify client with two methods. E. Review the label of the intravenous tubing. Explanation: The nurse will review the client's laboratory values, obtain correct ordered intravenous fluids, and identify client with two methods. The intravenous tubing should already have been labeled from the previous fluids so the nurse should review the label. Assisting the client with ambulation is not part of the intravenous fluid procedure.

A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents? A.Wear protective clothing. B. Reconstitute oral forms at the medication station. C. Wear a pair of sterile gloves when disconnecting intravenous (IV) tubing. D. Dispose of intravenous (IV) tubing in the trash container closest to the client.

Correct response: A. Wear protective clothing. Explanation: A nurse must wear two layers of chemotherapy-approved disposable gloves and protective clothing to prevent skin contact with chemotherapeutic agents. Reconstituted oral forms of chemotherapy, such as powders, should be prepared in the pharmacy and delivered in a sealed syringe. The nurse should use two layers of chemotherapy-approved gloves and a sterile gauze pad when priming IV tubing, connecting and disconnecting tubing, inserting syringes into vials, breaking glass ampules, or performing other procedures in which chemotherapeutic agents are being handled. Contaminated needles, syringes, IV tubes, and other equipment must be disposed of in a leak-proof, puncture-resistant container.

The nurse is preparing medications and has several partial dose administrations. For which medication(s) will the nurse ask another nurse to witness a waste of a partial dose? Select all that apply. A. fentanyl 25 mcg I.V. prescribed; available fentanyl 50 mcg/2 ml vial B. furosemide 40 mg I.V. prescribed; available furosemide 50 mg/5 ml vial C. lorazepam 2 mg I.V. prescribed; available lorazepam 2 mg/2 ml vial D. morphine 25 mg by mouth prescribed; available morphine 50 mg tablet E. metoprolol 5 mg I.V. prescribed; available 10 mg/10 ml vial

Correct response: A. fentanyl 25 mcg I.V. prescribed; available fentanyl 50 mcg/2 ml vial D. morphine 25 mg by mouth prescribed; available morphine 50 mg tablet Explanation: The nurse recognizes that all controlled substances require another nurse to witness the waste of a partial dose. The fentanyl and the morphine are both controlled substances with a partial dose that requires a waste, and therefore a witness to document the waste. The lorazepam is a controlled substance, but the prescribed dose requires the full dose available. Furosemide and metoprolol are not controlled substances and do not need a witness to document a waste.

What should a nurse do when administering pilocarpine? A. Apply pressure on the inner canthus to prevent systemic absorption. B. Administer at bedtime to prevent night blindness. C. Apply pressure on the outer canthus to prevent adverse reactions. D. Flush the client's eye with normal saline solution to prevent burning.

Correct response: Apply pressure on the inner canthus to prevent systemic absorption. Explanation: This medication is a Glaucoma medication and Saliva production stimulator. It can treat dry mouth caused by radiation treatment or Sjögren syndrome in its oral form. It can also reduce pressure in the eye from glaucoma. When administering pilocarpine, the nurse should apply pressure on the inner canthus to prevent systemic absorption of the drug. Pilocarpine doesn't cause night blindness. The outer canthus doesn't absorb eyedrops, so applying pressure there won't be helpful. Flushing the client's eye with normal saline solution after administering pilocarpine is contraindicated because it will wash the drug out of the eye, rendering treatment ineffective.

The nurse is teaching a client with hypertension about taking atenolol. What should the nurse instruct the client to do? Avoid sudden discontinuation of the drug. Monitor the blood pressure annually. Follow a 2-g sodium diet. Discontinue the medication if severe headaches develop.

Correct response: Avoid sudden discontinuation of the drug. Explanation: Atenolol is a beta-adrenergic antagonist indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a prescription. Blood pressure needs to be monitored more frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension.

The nurse instructs the client in mixing and administering regular and NPH insulin. Which statement indicates that the client needs additional instruction? A. "I draw up the regular insulin first." B. "I shake the bottle of NPH insulin before drawing it up." C. "I store the insulin in a cool place." D. "I insert the needle at a 90-degree angle."

Correct response: B. "I shake the bottle of NPH insulin before drawing it up." Explanation: NPH insulin should be rolled between the palms to mix it before drawing it up; shaking it will introduce air bubbles into the solution, which can cause inaccurate dosing. The client should draw up the regular insulin first, store the insulin in a cool place, and inject the insulin at a 90-degree angle.

What should be part of the nurse's teaching plan for a child with epilepsy being discharged on a regimen of phenytoin? A. Drink plenty of fluids. B. Brush teeth after each meal. C. Have someone be with the child during waking hours. D. Report signs of infection.

Correct response: Brush teeth after each meal. Explanation: Phenytoin can cause gingival hyperplasia. Children taking phenytoin should brush their teeth after every meal and at bedtime, and visit their dentist on a regular basis. Drinking plenty of fluids is not required while taking phenytoin. A child on phenytoin does not need to be observed during waking hours because the seizures should be under control. Infections do not occur with an increased incidence in clients receiving phenytoin.

The client's health care provider prescribes buspirone hydrochloride for increased anxiety. The nurse understands the health care provider's choice of this medication is based on what principle? Buspirone is often administered on an as-needed basis. Buspirone does not have any drug side effects. Buspirone is not habit forming. Buspirone is chemically similar to benzodiazepine medications.

Correct response: Buspirone is not habit forming. Explanation: Buspirone is not habit forming, is administered on a schedule, and does not work immediately. Buspirone may have side effects such as chest pain, dizziness, headache, drowsiness, or nausea. Buspirone hydrochloride is not chemically or pharmacologically related to benzodiazepines or other sedative medications.

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin. Client teaching about this drug should include which instruction? A. "Discontinue this medication after you've been seizure-free for 2 weeks." B. "Don't drive a car or operate machinery while taking this medication." C. "Schedule follow-up visits with your physician for blood tests." D. "Be aware that this drug may make your heart beat faster."

Correct response: C. "Schedule follow-up visits with your physician for blood tests." Explanation: A client taking phenytoin to control seizures must undergo routine blood testing to monitor for therapeutic serum phenytoin levels. Typically, the client takes the medication for 1 year after the original seizure, then is reevaluated for continued therapy. During phenytoin therapy, the client may drive and operate machinery. This drug may cause a decreased heart rate and hypotension.

x How should a nurse prepare a suspension before administration? A. by diluting it with normal saline solution B. by diluting it with 5% dextrose solution C. by shaking it so that all the drug particles are dispersed uniformly D. by crushing remaining particles with a mortar and pestle

Correct response: C. by shaking it so that all the drug particles are dispersed uniformly Explanation: The nurse should shake a suspension before administration to disperse drug particles uniformly. Diluting the suspension and crushing particles aren't recommended for this drug form.

A client's caretaker calls the home care nurse and states accidentally puncturing the central venous catheter after discontinuing the total parenteral nutrition. What instructions should the nurse provide to the caretaker? A. Contact 911. B. Clamp the catheter. C. Remove the catheter. D. Position client on left side with head higher than the feet.

Correct response: Clamp the catheter. Explanation: The nurse should instruct the caretaker to clamp the catheter to prevent the client from experiencing an air embolism. The client should be positioned on the left side with head lower than the feet, not higher. The catheter should not be removed by the caretaker; it will need to be removed in an acute care or outpatient setting by a healthcare provider. As the client is not experiencing signs or symptoms of an air embolism or other complication, there is no need to contact 911 at this time.

A primigravid client who was successfully treated for preterm labor at 30 weeks' gestation had a history of mild hyperthyroidism before becoming pregnant. What instructions should the nurse include in the plan of care? A. Continue taking low-dose oral propylthiouracil as prescribed. B. Discontinue taking the methimazole until after the birth of the neonate. C. Consider breastfeeding the neonate after the birth. D. Contact the health care provider (HCP) if bradycardia occurs.

Correct response: Continue taking low-dose oral propylthiouracil as prescribed. Explanation: Although thioamides such as propylthiouracil and methimazole are considered teratogenic to the fetus and can lead to congenital hyperthyroidism (goiter) in the neonate, they still represent the treatment of choice. The client should be regulated on the lowest possible dose. Hyperthyroidism is associated with preterm labor and a low-birth-weight infant, so the client should contact the HCP if the contractions begin again. The client should not be urged to breastfeed because medications such as propylthiouracil and methimazole are secreted in breast milk. Tachycardia (not bradycardia) is associated with thyroid storm, a medical emergency, and should be reported to the HCP.

The supervisor is performing a chart review. The nurse can be held legally liable for which documentation? A. 0800 administered 2 mg hydromorphone IVP per PRN orders of 1 to 2 mg every 4 hours -BSmith, RN B. 0900 Withheld digoxin dose. Client's apical pulse is 56 beats/min -BSmith, RN C. 0900 Withheld mononitrate dose. Client's blood pressure is 80/40 mmHg -BSmith, RN D. 1200 Administered cephalosporin. The client has an allergy to penicillin -BSmith, RN

Correct response: D. 1200 Administered cephalosporin. The client has an allergy to penicillin -BSmith, RN Explanation: There is a cross-sensitivity between cephalosporin and penicillin, and the drug should not have been given. When a dosage range is ordered, any dose in that range is acceptable. Digoxin is a cardiac glycoside that acts to improve the efficiency of the heart and may slow the heart rate and the drug should not ordinarily be given if the apical pulse is less the 60. Mononitrate is a nitrate that can cause vasodilation and should not be given when hypotension is present.

Foods that contain tyramine

aged cheese, cured meats, picketed or fermented vegetables, fresh citrus, dried fruit, ripe bananas, rip avocados, smoked fish, some beers, and red wine

muscle weakness & irregular pulse related to what electrolyte imbalance?

hypokalemia

headaches & poor tissue turgor is related to what electrolyte imbalance?

hyponatremia

akathisia

inability to sit still, is restless and fidgety, and paces around the unit. Extrapyramidal adverse effects