Module 8
A client's dinner intake includes a glass of milk (8 oz), a cup of tea (6 oz), a glass of water (8 oz), and gelatin (4 oz). How many milliliters of fluid has the client consumed?
780 mL RATIONALE: The client consumed a total of 26 oz of fluid. Because 1 oz is equal to 30 mL, you must multiply 26 oz by 30 mL, which yields 780 mL.
Spironolactone, a potassium-retaining diuretic, is prescribed for a client with heart failure, and the nurse provides medication instructions to the client. Which statement by the client indicates an understanding of the instructions? a) "I need to avoid foods that contain potassium." b) "I should take the medication on an empty stomach." c) "I need to eat a banana or drink a glass of orange juice every day." d) "I need to drink at least 10 to 12 glasses of water per day while I'm taking this medication."
a) "I need to avoid foods that contain potassium." RATIONALE: Spironolactone is a potassium-retaining diuretic. Therefore the client should avoid foods, such as bananas and orange juice, that contain potassium. The client should take the medication with food to enhance medication absorption. The client with heart failure should limit fluid intake as prescribed by the health care provider.
A client with tuberculosis has been taking isoniazid, and now the health care provider has added rifampin to the medication regimen. The client calls the nurse and reports that her urine has been red-orange since she started taking the rifampin. Which response should the nurse give to the client? a) "This is an expected side effect of the rifampin." b) "Bring a urine specimen to the health care provider's office for analysis." c) "The change in urine color is a result of the combination of medications." d) "Increase your fluid intake. The medication may be causing hemorrhagic cystitis."
a) "This is an expected side effect of the rifampin." RATIONALE: Rifampin is an antitubercular medication that is used in conjunction with at least one other antitubercular medication for the treatment of tuberculosis. An expected side effect is a red-orange or red-brown discoloration of the urine, feces, saliva, skin, sweat, sputum, or tears. Because this side effect is expected, it is not necessary to have the client bring a specimen to the health care provider's office. The change in urine color is not a result of treatment with a combination of medications. Rifampin does not cause hemorrhagic cystitis, although some chemotherapeutic medications do cause this condition.
The nurse is participating in an interprofessional care conference. The health care provider tells the resident that the client needs an IV infusion of an isotonic solution. Which solution should the nurse expect the medical resident to prescribe? a) 0.9% NS b) 0.45% NS c) 10% dextrose in water d) 5% dextrose in 0.9% normal saline
a) 0.9% NS RATIONALE: An isotonic solution (a solution with the same osmolality as body fluids) increases the volume of extracellular fluid volume. One example of such a solution is 0.9% NS. A hypotonic solution is a solution that is more dilute or has a lower osmolality than body fluids — for instance, 0.45% NS. A hypertonic solution is more concentrated or has a higher osmolality than body fluids. Examples of such fluids include 10% dextrose in water and 5% dextrose in 0.9% normal saline solution.
Cyclosporine is prescribed for a client who has undergone a kidney transplant. Which should the nurse plan to monitor most closely? a) Temperature b) Platelet count c) Apical heart rate d) Peripheral pulses
a) Temperature RATIONALE: Cyclosporine is an immunosuppressant used to prevent organ rejection. The most common adverse effects of cyclosporine are nephrotoxicity, infection, hypertension, tremor, and hirsutism. Of these, nephrotoxicity and infection are the most important. Therefore the client's temperature should be monitored closely, because an increase in temperature is an indication of infection. Apical heart rate, platelet count, and peripheral pulses are not specifically associated with the effects of this medication.
A nurse reviewing laboratory results sees that the serum phenytoin level of a client who is taking oral phenytoin, 300 mg/day, is 22 mcg/mL. Which action should the nurse take first on the basis of this finding? a) Call the client's health care provider b) Administer the next scheduled dose c) Place the laboratory result form in the client's record d) Inform the client that the result is within the therapeutic range
a) Call the client's health care provider RATIONALE: The therapeutic serum range of phenytoin is 10 to 20 mcg/mL. A level below 10 mcg/mL is too low to control seizures and reflects a need to increase the dosage of phenytoin. A level higher than 20 mcg/mL indicates toxicity and a need to notify the health care provider. The nurse would place the laboratory results in the client's record after notifying the health care provider.
Timolol maleate eyedrops have been prescribed to reduce intraocular pressure in a client with open-angle glaucoma. When teaching the client about the medication, the nurse ensures that the client knows how to perform which procedure? a) Check his pulse b) Measure his weight c) Take his temperature d) Measure his intake and output
a) Check his pulse RATIONALE: Timolol maleate is a beta-adrenergic-blocking medication that reduces intraocular pressure by diminishing the production of aqueous humor. Beta-blockers can be absorbed in amounts sufficient to cause systemic effects. Blockade of cardiac beta-1 receptors can produce bradycardia and atrioventricular heart block. Therefore the client should be taught how to take the pulse. Weight, temperature, and intake and output are not directly related to the action or side/adverse effects of this medication.
A nurse is preparing to administer enteric-coated acetylsalicylic acid tablets orally to a client. When the nurse brings the medication to the client, the client tells the nurse that she has difficulty swallowing and will not be able to swallow the pills. Which action is most appropriate for the nurse to take? a) Contacting the health care provider b) Administering an elixir form of the medication c) Crushing the pills and mixing them into applesauce d) Administering the suppository form of the medication
a) Contacting the health care provider RATIONALE: Enteric-coated tablets, which are absorbed in the small intestine, should not be crushed, because the medication could irritate the stomach. For these reasons, an elixir form of a medication should not be given in place of enteric-coated tablets. Also, aspirin is not available in elixir form. The nurse would not administer a medication by way of a route that had not been prescribed. Thus the only correct option is to contact the health care provider.
The nurse has obtained a unit of packed RBCs from the blood bank for administration to a client. While preparing to administer the transfusion, the nurse is called to attend to an emergency involving another client. Before leaving to go to the other client, what should the nurse ask another staff member to do? a) Return the blood to the blood bank b) Place the blood in the nursing unit's refrigerator c) Attach the blood to the client's IV line because the client's identity and the identifying information on the unit of blood have already been matched d) Bring the unit of blood to the client's bedside and explain to the client that the blood will be infused once the emergency situation has been taken care of
a) Return the blood to the blood bank RATIONALE: Blood bank safety protocol dictates that refrigerated blood components not be returned to inventory if they have been warmed to more than 10° C (50° F). Therefore the maximal amount of time for which a unit of blood can be out of storage is 30 minutes. Thus, the nurse would not leave the unit of blood at the client's bedside or attach it to the client's IV line. Blood is not placed in the nursing unit refrigerator, because its temperature may not be adequate for blood storage. The appropriate nursing action is to have the unit of blood returned to the blood bank.
The nurse obtains a bag of parenteral nutrition (PN) solution from the nursing unit refrigerator. On inspecting the solution, the nurse notes that it is cloudy. Which action should the nurse take? a) Return the solution to the pharmacy b) Shake the solution vigorously to disperse the cloudiness c) Assume that the lipids (fat emulsion) has been added to the PN solution d) Allow the solution to warm to room temperature and then recheck the solution
a) Return the solution to the pharmacy RATIONALE: The nurse must check the PN solution before administering it. Cloudiness is a sign of contamination. If contamination is suspected, the only safe option is to promptly return the solution to the pharmacy. Shaking the solution vigorously to disperse the cloudiness, assuming that the lipid emulsion has been added to the solution, and allowing the solution to warm to room temperature and rechecking it are all incorrect actions that do not address the abnormal finding.
A topical glucocorticoid preparation has been prescribed for a client in whom local dermatitis has developed as a result of an insect bite. What should the nurse include when teaching the client about the medication? a) Rub the cream gently into the skin b) Cover the site with plastic wrap after applying the cream c) Apply an occlusive dressing over the site after applying the cream d) Apply the cream in a thick layer over the site of the bite and on 2 inches of surrounding skin
a) Rub the cream gently into the skin RATIONALE: Topical glucocorticoids can be absorbed into the systemic circulation. Therefore they should be applied in a thin layer and gently rubbed into the skin. The client is told not to use occlusive dressings (e.g., bandages, plastic wrap) unless instructed to do so by the health care provider.
The nurse provides medication instructions to a client. Which statements by the client indicate the need for follow-up and additional teaching? Select all that apply. a) "I need to check my pulse before taking my heart medication." b) "I need to stop taking the medication if I have any side effects." c) "I can take herbal medications if I want, because they come from plants." d) "I should wear a Medic-Alert bracelet for as long as I'm taking this blood thinner." e) "I need to take this antibiotic until all of the capsules are all gone, even if I'm feeling better."
b) "I need to stop taking the medication if I have any side effects." c) "I can take herbal medications if I want, because they come from plants." RATIONALE: One component of medication instructions is teaching the client how to take his temperature, pulse, and blood pressure. The client is also taught never to adjust a dose or abruptly stop taking a medication. If side effects or adverse effects occur, the client should contact the health care provider. Over-the-counter medication, including herbal preparations, must be avoided unless specifically approved by the health care provider, because they may interact with prescribed medications. Clients taking medications such as anticoagulants, oral hypoglycemics or insulin, certain cardiac medications, corticosteroids and glucocorticoids, antimyasthenic medications, anticonvulsants, and monoamine oxidase inhibitors need to wear a Medic-Alert bracelet or carry a Medic-Alert card. Medication compliance is important, and the importance of completing the prescribed medication regimen must be stressed to the client.
A nurse monitoring a client who is receiving intravenous theophylline checks the client's most recent blood theophylline level. The nurse documents that the level is in the therapeutic range if which value is reported? a) 8 mcg/mL b) 14 mcg/mL c) 24 mcg/mL d) 32 mcg/mL
b) 14 mcg/mL RATIONALE: The therapeutic theophylline level ranges from 10 to 20 mcg/mL. If the level is below 10 mcg/mL, an increase in the infusion rate may be prescribed. A level greater than 20 mcg/mL indicates toxicity.
The nurses determines which clients are candidates for parenteral nutrition (PN)? Select all that apply. a) A client with pneumonia b) A client with a severe burn injury c) A client with congestive heart failure d) A client scheduled for cholecystectomy e) A client with diabetes mellitus who has an ulcer on the right ankle f) A client undergoing chemotherapy who is experiencing severe vomiting and diarrhea
b) A client with a severe burn injury f) A client undergoing chemotherapy who is experiencing severe vomiting and diarrhea RATIONALE: PN is indicated when the GI tract is severely dysfunctional or nonfunctional; when the client has undergone multiple GI surgeries or has sustained GI trauma; in clients experiencing severe intolerance of enteral feedings or intestinal obstruction; and in clients with other conditions in which the bowel needs to rest for healing. Conditions include AIDS, cancer, malnutrition, burns, chronic vomiting and diarrhea, diverticulitis, malnutrition, inflammatory bowel disease, pancreatitis, severe anorexia nervosa, and hypermetabolic states such as sepsis.
Rectally administered lactulose is prescribed for a client with hepatic encephalopathy. Which parameter should the nurse monitor to evaluate the effectiveness of the medication? a) Blood pressure b) Ammonia level c) Electrolyte levels d) Looseness of stools
b) Ammonia level RATIONALE: Lactulose is a hyperosmotic laxative and ammonia detoxicant. It can enhance intestinal excretion of ammonia and decrease the blood ammonia level in a client with portal hypertension and hepatic encephalopathy. Diarrhea is an indicator of overdose, not effectiveness. Used correctly, the medication should result in the production of two or three soft stools per day. Blood pressure is not associated with the action or effectiveness of this medication. Electrolyte levels are monitored in clients who must take this medication frequently, in large doses, or for prolonged periods because of the risk of electrolyte disturbance.
A client who is receiving a continuous IV infusion through a peripheral site suddenly complains of pain along the vein at the location of the catheter. The nurse quickly assesses the client and notes a weak, rapid pulse; cyanosis of the nail beds; and a decrease in blood pressure. Suspecting catheter embolism, the nurse removes the IV catheter and sees that the tip of the catheter has broken off. What immediate action should the nurse take? a) Start an IV line at a different site b) Apply a tourniquet high on the limb of the IV site c) Call the operating room to alert the staff that the client will need surgery d) Call the radiography department to request an x-ray of the client's arm and shoulder
b) Apply a tourniquet high on the limb of the IV site RATIONALE: A catheter embolism occurs when the tip of the IV catheter breaks off and floats freely in a vessel. This can lead to an embolus. The signs of catheter embolism include pain along the vein; diminished blood pressure; weak, rapid pulse; cyanosis of the nail beds; and loss of consciousness. The nurse would remove the catheter carefully, inspect the catheter once it has been removed, and place a tourniquet high on the limb containing the IV site if the catheter tip has broken off. The health care provider is then notified. The client is prepared for anx-ray and for surgery to remove catheter fragments, if prescribed.
A nurse is observing a new nurse employee who is preparing to administer 1 inch (2.5 cm) of topical nitroglycerin ointment to a client with angina pectoris. Which actions indicate the new nurse employee needs further education? Select all that apply. a) Wearing gloves b) Applying the ointment to skin with hair c) Removing previously applied ointment d) Rubbing the ointment into the client's skin e) Measuring out the correct amount of ointment on the paper applicator f) Taping the paper applicator in place once the ointment has been applied
b) Applying the ointment to skin with hair d) Rubbing the ointment into the client's skin RATIONALE: To promote medication absorption as intended, the nurse would avoid applying the ointment to skin with hair and would also avoid rubbing the ointment into the skin. The nurse always wears gloves when applying topical medications to a client; in this case, gloves are especially important because the nurse could be subject to the effects of the medication if it were to come into contact with the nurse's skin. Before applying nitroglycerin ointment, the nurse would remove the previously applied ointment and cleanse the skin. The correct amount of medication is measured out on the appropriate paper applicator, after which the applicator is taped in place on the client's body.
A client with Hodgkin's disease will be receiving chemotherapy with doxorubicin. Which action should the nurse plan to take as a means of monitoring the client for toxicity specific to this medication? a) Checking the client's temperature b) Attaching a cardiac monitor to the client c) Assessing the client for peripheral edema d) Drawing a blood specimen to check the client's platelet count
b) Attaching a cardiac monitor to the client RATIONALE: Doxorubicin can cause both acute and delayed injury to the heart. Acute effects (dysrhythmias, electrocardiographic changes) may develop within minutes of administration. (In most cases these reactions are transient, lasting no more than 2 weeks.) Delayed cardiotoxicity, which appears as heart failure resulting from diffuse cardiomyopathy, is often unresponsive to treatment. Checking the client's temperature, assessing the client for peripheral edema, and checking the client's platelet count may all be sound nursing interventions, but they are not specifically related to cardiotoxicity, a toxic effect of doxorubicin.
Two registered nurses confirming blood product compatibility and verifying client identity for a client who is to receive a unit of packed RBCs are comparing the name and number on the client's identification band with the name and number on the unit of blood. The nurses note that the numbers are not identical. What should the nurses do? a) Hang the unit of blood b) Contact the blood bank c) Continue verifying client identity, then notify the health care provider d) Ask the unit secretary to prepare another identification band for the client that contains the number noted on the unit of blood
b) Contact the blood bank RATIONALE: Two licensed nurses must check the health care provider's prescription, the client's identity, and the client's identification band and number, verifying that the name and number are identical to those on the blood component tag. At the bedside, the client is asked to state his or her name, which the nurse compares with the name on the client's ID band. The blood bag tag and label and the blood requisition form are assessed to ensure that ABO and Rh types are compatible, and the blood bag label is also checked to ensure that the correct components have been issued. If an inconsistency is found, the blood bank is notified immediately. Hanging the unit of blood, continuing to verify the client's identity, notifying the health care provider, and asking the unit secretary to prepare another identification band for the client that contains the number noted on the unit of blood are all incorrect choices. Additionally, there is no useful reason to notify the health care provider.
A client with terminal cancer is receiving morphine sulfate by way of continuous IV infusion. The nurse checks the client's vital signs and notes a pulse rate of 68 beats/min, a blood pressure of 100/58 mm Hg, and a respiratory rate of 10 breaths/min. Which action should the nurse take? a) Decrease the rate of infusion b) Contact the health care provider c) Ask the client to rate the pain level d) Continue to monitor the client's vital signs
b) Contact the health care provider RATIONALE: Respiratory depression is the most serious adverse effect of morphine sulfate. If the client's respiratory rate is slower than 12 breaths/min or if bradycardia develops (slower than 60 beats/min), the nurse would withhold the medication (not just decrease the rate of the infusion) and notify the health care provider. Although the nurse would assess the client's pain level and continue to monitor the client's vital signs, contacting the health care provider is the appropriate action.
The nurse is monitoring a client receiving a blood transfusion. One hour after the transfusion is started, the client complains that her skin is extremely itchy. On assessing the client's skin, the nurse notes a rash and suspects a transfusion reaction. Which action should the nurse take after immediately stopping the transfusion? a) Removing the IV catheter b) Contacting the health care provider c) Completing a transfusion reaction report d) Rechecking the blood bag tags against the client's identification band
b) Contacting the health care provider RATIONALE: When a transfusion reaction occurs, the nurse first stops the blood transfusion, then maintains a patent IV line with normal saline solution and immediately notifies the health care provider and blood bank. After taking these actions, the nurse would recheck the blood bag tags against the client's identification band, check the client's vital signs and urine output, treat the client's symptoms in accordance with the health care provider's prescriptions, send the blood bag and tubing to the blood bank, complete a transfusion reaction report and document the reaction in the client's record, and collect required blood and urine samples in accordance with agency protocol and health care provider's prescriptions.
The nurse is developing a plan of care for a client who will receive a continuous IV infusion of 5% dextrose at a rate of 100 mL/hr. How frequently should the nurse plan to change the bag of IV fluids? a) Weekly b) Every 24 hours c) Every 48 hours d) Every 72 hours
b) Every 24 hours RATIONALE: As a means of helping prevent complications associated with IV therapy (systemic infection), the bag of IV fluids should be changed every 24 hours. Other times, such as every 48 to 72 hours or weekly, would allow time for bacteria to proliferate.
The IV catheter is inserted and infusion of the prescribed solution is started. The ED nurse transports Josephine to the medical unit for admission and provides a detailed report on her status to the nurse on the medical unit. On admission to the medical unit, Josephine complains of pain at the venipuncture site. Checking the venipuncture site, the nurse notes that it is swollen and cool to touch and also sees that the solution is not infusing. How does the nurse interpret these findings? a) The IV line needs to be flushed. b) Infiltration of the IV site has occurred. c) Phlebitis caused by the IV catheter is beginning to set in. d) Heat should be applied to the venipuncture site to dilate the vein so that the solution will infuse as prescribed.
b) Infiltration of the IV site has occurred.
While reviewing the results of Helena's laboratory studies, the nurse notes that Helena's hemoglobin is 6.8 g/dL (68 mmol/L) and her hematocrit is 24%. The nurse reports the results to the health care provider, who prescribes a transfusion of 1 unit of packed red blood cells (RBCs). Which are part of the correct procedures for administering the blood? Select all that apply. a) Using a 22-gauge needle to infuse the blood b) Monitoring Helena for circulatory overload during the infusion c) Planning to ensure that the infusion will be complete in 4 hours d) Monitoring Helena closely for a transfusion reaction, especially during the first 50 mL of the transfusion e) Ensuring that the transfusion is started within 1 hour of the blood bag's delivery to the nursing unit from the blood bank.
b) Monitoring Helena for circulatory overload during the infusion c) Planning to ensure that the infusion will be complete in 4 hours d) Monitoring Helena closely for a transfusion reaction, especially during the first 50 mL of the transfusion RATIONALE: The normal hemoglobin reading in a female client is approximately 12 to 15 g/dL, and the normal hematocrit is 35% to 47%. To avoid septicemia, the transfusion time should not exceed 4 hours. If the client's size or condition does not allow infusion within 4 hours, the blood bank may split the unit into smaller portions. Helena will be monitored for circulatory overload because of she is 79 years of age; older client is one population at risk for circulatory overload. Although a transfusion reaction can occur at any time, it most likely occurs with the first 15 minutes or first 50 mL of infused solution. Blood bank regulations prevent the return of components to the blood bank inventory that has been warmed to more than 50° F, so 30 minutes is considered to be the maximum time out of monitored storage in most hospitals. The gauge of the needle used for transfusion varies with the product being infused. Generally a 19-gauge or larger needle is required to achieve the maximal flow rate. The lumen of a 22-gauge needle would be too small for the infusion of blood.
The nurse administers the IV diphenhydramine hydrochloride to Helena and begins the blood transfusion. After 15 minutes, Helena has shown no signs of a reaction and her vital signs are stable. The nurse increases the flow rate of the infusion and notes that the blood is infusing more slowly than the set rate. The nurse prepares to dilute the blood per agency policy. Which intravenous (IV) solution is essential for the nurse to select for dilution? a) 5% dextrose in water b) Normal saline solution c) Lactated Ringer's solution d) 5% dextrose in 0.45% normal saline solution
b) Normal saline solution RATIONALE: Normal saline solution is the only solution that can be used to dilute blood. Any other solution will cause hemolysis; therefore 5% dextrose in water, lactated Ringer's solution, and 5% dextrose in 0.45% normal saline solution are all incorrect choices.
The registered nurse is a case manager for the emergency department. A client is brought to the emergency department by emergency medical services after sustaining a gunshot wound to the abdomen. The client, bleeding profusely, requires an immediate transfusion of whole blood, but his blood type is unknown. When conducting a case review, the case manager determines appropriate action was taken if which type of blood was requested from the blood bank? a) O-positive b) O-negative c) AB-positive d) AB-negative
b) O-negative RATIONALE: Whole blood is used in the event of major blood loss. Typing and crossmatching are normally performed to identify the client's blood type (A, B, AB, O), to check for the presence of the Rh factor, and to ensure compatibility with the donor's blood. In an extreme emergency, however, the client may be transfused with O-negative blood, which is considered the "universal" donor blood type. AB-positive is the universal recipient type — a client with this blood type may be given any of the types of blood safely.
An IV catheter was inserted into a client 1 hour ago. Assessing the IV site, the nurse notes the presence of bruising. The nurse also finds that the area is swollen, and the client complains of pain at the site. Which action by the nurse is most appropriate? a) Notifying the health care provider of the findings b) Removing the IV catheter and applying pressure to the site c) Elevating the extremity and rechecking the site in 1 hour for a decrease in the swelling d) Telling the client that the bruising is normal and occurred as a result of the IV insertion
b) Removing the IV catheter and applying pressure to the site RATIONALE: A hematoma is a collection of blood in the tissue that occurs after an unsuccessful venipuncture or after a venipuncture is discontinued. It is characterized by discoloration, bruising, and swelling around the IV site. The client may also complain of pain at the site. If a hematoma develops, the nurse removes the IV catheter, elevates the extremity, and applies pressure. This occurrence is not normal, but it is not necessary to notify the health care provider of this complication unless agency policy indicates that this should be done.
Oral prednisone, 10 mg/day, has been prescribed for a hospitalized client with a history of type 1 diabetes mellitus for the treatment of an acute exacerbation of asthma. The nurse should monitor the client closely for which occurrence? a) Signs of hypoglycemia b) Signs of hyperglycemia c) The need to decrease the prescribed daily insulin dose d) The need to change the prescribed daily insulin to an oral hypoglycemic medication
b) Signs of hyperglycemia RATIONALE: Because of their effect on glucose production and utilization, glucocorticoids can increase the plasma glucose level, causing hyperglycemia and glycosuria. Clients with diabetes mellitus may need to increase the dosage of insulin or oral hypoglycemic medications during treatment with a glucocorticoid. Decreasing the prescribed insulin dose, needing to change the prescribed insulin to an oral hypoglycemic medication, and watching for signs of hypoglycemia are all therefore incorrect.
The nurse is working with a new nurse employee who is hanging a unit of packed RBCs. The nurse realizes the new nurse employee has taken correct action if the nurse takes which step once the nurse has hung the blood and adjusted the flow rate? a) Taking the client's vital signs b) Staying with the client and monitoring him closely for 15 minutes c) Asking the client whether he has ever had a reaction to a blood transfusion d) Placing the call bell next to the client and instructing him to call if he experiences anything unusual
b) Staying with the client and monitoring him closely for 15 minutes RATIONALE: The first 10 to 15 minutes of any transfusion is the most critical period. If a major ABO incompatibility exists or a severe allergic reaction such as anaphylaxis is going to occur, it is usually evident within the first 50 mL of the transfusion. Therefore the transfusion should be started at a slow rate and the client monitored closely for the first 15 minutes. If no reaction is noted during the first 15 minutes, the infusion may be increased to the prescribed rate. The client is asked about previous reactions to blood transfusions before the blood is infused. Vital signs are taken before the transfusion is begun, after the first 15 minutes, and every hour until 1 hour has elapsed since the transfusion was completed. Before leaving the client, the nurse places the call bell next to him and instructs him to call if he experiences any unusual feelings or emotions.
A nurse is preparing to administer digoxin, 0.125 mg orally, to a client with heart failure. Which findings indicate the need to withhold the medication and contact the health care provider? Select all that apply. a) The client complains of being hungry. b) The client complains of double vision. c) The client's digoxin level is 1.8 ng/mL. d) The client's potassium level is 3.0 mEq/L (3.0 mmol/L). e) The client's apical heart rate is 62 beats/min.
b) The client complains of double vision. d) The client's potassium level is 3.0 mEq/L (3.0 mmol/L). RATIONALE: The therapeutic (digoxin) level ranges from 0.5 to 2.0 ng/mL. Signs of toxicity include anorexia or nausea and vomiting; visual disturbances: diplopia, blurred vision, yellow-green halos; bradycardia (heart rate slower than 60 beats/min); and photophobia. The health care provider is alerted if signs of toxicity are noted. An increased risk of toxicity exists in clients with hypokalemia, so the health care provider is notified if hypokalemia is present. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).
Buspirone, a nonbenzodiazepine anxiolytic, is prescribed for a client to treat anxiety, and the nurse provides information to the client about the medication. The nurse should provide which information to the client? a) The medication is addictive. b) The medication does not usually cause sedation. c) The medication relieves anxiety immediately, with the first dose. d) The medication can intensify the effects of other CNS depressants.
b) The medication does not usually cause sedation. RATIONALE: Buspirone is an anxiolytic used to reduce anxiety. Common side effects include dizziness, nausea, headache, nervousness, lightedheadedness, and excitement. It does not usually cause sedation, has no abuse potential, and does not intensify the effects of CNS depressants. Antianxiety effects take at least a week to develop.
Allopurinol has been prescribed to treat hyperuricemia in a client with gout, and the nurse provides instructions to the client for the medication. Which statement by the client indicates the need for additional instruction? a) "I should take the medication with food." b) "I need to stop putting gravy on my food." c) "I'll need to limit my fluid intake while I'm taking this medication." d) "I'll need to have my blood level of the medicine checked while I'm taking it."
c) "I'll need to limit my fluid intake while I'm taking this medication." RATIONALE: Allopurinol, used to treat gout, reduces the concentrations of uric acid in serum and urine. The client should increase fluid intake to at least 2000 to 3000 mL/day to prevent renal injury. The client should also avoid foods high in purines (e.g., gravy, wine, alcohol, organ meats, sardines, salmon) to help decrease levels of uric acid. The medication should be taken with meals or milk to minimize GI distress. The client should have periodic complete blood cell counts, as well as determinations of serum and blood levels of uric acid, as prescribed.
A nurse is instructing a client about the use of sulfisoxazole, which has been prescribed to treat the client's urinary tract infection. Which instructions should the nurse provide to the client? Select all that apply. a) Expect itching to develop. b) Limit fluid intake to prevent edema. c) Apply sunscreen if exposure to sunlight is expected. d) Use over-the-counter corticosteroid cream for itchy rash. e) Take the medication on an empty stomach with a full glass of water.
c) Apply sunscreen if exposure to sunlight is expected. e) Take the medication on an empty stomach with a full glass of water. RATIONALE: Sulfisoxazole is a sulfonamide. The appearance of a rash indicates hypersensitivity to the medication; the client is instructed to stop the medication and contact the health care provider if itching or a rash occurs. The client should not use over-the-counter medications unless they are specifically prescribed. The client is also instructed to take the medication on an empty stomach with a full glass of water; to avoid prolonged exposure to sunlight, wear protective clothing when in the sun, and apply a sunscreen to skin exposed to sunlight; and to consume eight to 10 glasses of water each day to minimize the risk of renal damage.
A client receiving PN is exhibiting signs of an air embolism. Immediately after placing the client's head lower than the feet, how should the nurse next position the client? a) Prone b) On her back c) On the left side d) On the right side
c) On the left side RATIONALE: When air embolism is suspected, the client should be placed in a left side-lying position with the head lower than the feet. This position is used to help minimize the effect of the air travelling as a bolus to the lungs by trapping it in the right side of the heart. Therefore the other options are incorrect.
Levodopa is prescribed for a client with Parkinson disease. Which vitamin does the nurse instruct the client to avoid while taking the levodopa? a) Thiamine b) Riboflavin c) Pyridoxine d) Ascorbic acid
c) Pyridoxine RATIONALE: Pyridoxine can decrease the amount of levodopa that reaches the CNS. As a result, the therapeutic effect of levodopa is reduced. The client taking levodopa should be informed about this interaction and instructed to avoid multivitamin preparations containing pyridoxine. Thiamine, riboflavin, and ascorbic acid do not need to be avoided by the client taking levodopa; these medications do not affect the amount of levodopa reaching the CNS.
A pregnant client is receiving an IV infusion of oxytocin. Monitoring the client closely, the nurse suddenly notes the presence of uterine hypertonicity. Which action should the nurse take immediately? a) Document the finding b) Turn the client on her side c) Stop the oxytocin infusion d) Increase the rate of infusion of the nonadditive IV solution
c) Stop the oxytocin infusion RATIONALE: Oxytocin is an oxytocic agent used to induce labor. If uterine hypertonicity or a nonreassuring FHR occurs, the nurse must intervene to reduce uterine activity and increase fetal oxygenation. The nurse would immediately stop the oxytocin infusion, increase the rate of the nonadditive (e.g., normal saline) IV solution, place the client in a side-lying position, and administer oxygen by way of face mask at a rate of 8 to 10 L/minute. The nurse would then notify the health care provider, continue monitoring the client, and document the occurrence and findings. However, the immediate action is stopping the infusion.
Tranylcypromine sulfate is prescribed for a client with depression, and the nurse provides medication instructions to the client. Which statement by the client indicates a need for further instruction? a) "I shouldn't eat bananas." b) "I should get out of bed slowly in the morning." c) "I need to carry a Medic-Alert card in my wallet." d) "If I get a headache or any neck soreness, I can take some pain medication."
d) "If I get a headache or any neck soreness, I can take some pain medication." RATIONALE: Tranylcypromine sulfate, an MAOI, is used to treat depression. Certain pain medications, when combined with an MAOI, can cause a hypertensive crisis. The client is instructed to avoid consuming foods that contain tyramine (bananas) to help prevent hypertensive crisis. The client is also instructed to change position slowly to help prevent orthostatic hypotension and is told that signs of hypertensive crisis (e.g., headache or neck soreness or stiffness) must be reported to the health care provider immediately. The client is instructed to wear a Medic-Alert bracelet or carry a Medic-Alert card to alert others as necessary that an MAOI is being taken.
A nurse provides medication instructions to a client with angina who will be taking nitroglycerin sublingually as needed for chest pain. Which statement by the client indicates the need for further teaching? a) "I should store the medication in a dark, tightly closed bottle." b) "I need to check the expiration date on the medication bottle." c) "If I get a headache from the medication, I can take acetaminophen." d) "If the first tablet doesn't relieve my chest pain, I should put 2 tablets under my tongue 5 minutes after taking the first."
d) "If the first tablet doesn't relieve my chest pain, I should put 2 tablets under my tongue 5 minutes after taking the first." RATIONALE: The nurse should instruct the client to take a sip of water before taking the medication, because mouth dryness may inhibit absorption. To terminate an acute anginal attack, sublingual nitroglycerin should be administered as soon as pain begins. Administration should not be delayed until the pain has become severe. According to current guidelines for the non-hospitalized client, if pain is not relieved in 5 minutes after taking the first nitroglycerin tablet, the client should call emergency medical services (911), since anginal pain that does not respond to nitroglycerin may indicate myocardial infarction. While awaiting emergency care, the client can take 1 more tablet, and then a third tablet 5 minutes later. The client should place the tablet under the tongue and allow it to fully dissolve. The nurse also instructs the client to store the medication in a dark, tightly closed bottle and to check the expiration date, because expiration may occur within 6 months of the medication's being dispensed. The client is instructed to take acetaminophen for headache.
A client is taking capreomycin sulfate as a component of pharmacological treatment for tuberculosis. The client calls the nurse at the health care provider's office and reports that he is experiencing ringing in the ears. How should the nurse respond? a) "You should stop taking the medication immediately." b) "Ringing in the ears is a harmless effect of the medication." c) "Ringing in the ears is an expected effect of the medication." d) "You need to speak to the health care provider about the problem."
d) "You need to speak to the health care provider about the problem." RATIONALE: Capreomycin is a second-line antituberculosis medication that is administered in conjunction with a first-line medication to treat tuberculosis. It can cause damage to cranial nerve VIII (ototoxicity), resulting in hearing loss, tinnitus, and disturbance of balance. If signs of ototoxicity occur, the health care provider must be notified. Ototoxicity is not an expected or harmless effect of the medication. The nurse does not adjust a dosage or discontinue a medication.
The nurse is caring for a client with breast cancer who has been undergoing chemotherapy. Blood tests indicate a low platelet count. A platelet transfusion is prescribed, and the nurse obtains the platelets from the blood bank. After carrying out the pretransfusion protocol, the nurse should administer the transfusion over what period of time? a) 2 hours b) 4 hours c) 6 hours d) 15 to 30 minutes
d) 15 to 30 minutes RATIONALE: The volume of a unit of platelets may vary from 200 mL for single-donor platelets to 300 mL per unit for pooled platelets. Because the platelet is a fragile cell, platelet transfusions are administered rapidly once they have been brought to the client's room, usually over the course of 15 to 30 minutes. The other options are time frames that are too long for the administration of a platelet transfusion.
The nurse is working with a newly licensed nurse who is undergoing education prior to inserting an IV and is gathering the equipment needed to start an IV line in an older client who will be receiving an IV solution of 0.9% NS. The nurse realizes that teaching has been effective if the newly licensed nurse selects which gauge of catheter for this client? a) 14 b) 16 c) 19 d) 21
d) 21 RATIONALE: For an older client, the smallest gauge IV catheter possible should be used. A gauge of 21 or smaller is preferred. A 14-, 16-, 18-, or 19-gauge needle is used for rapid emergency administration of fluids, blood products, or anesthetics, as well as other products of thicker viscosity than that of standard IV fluids.
The ED health care provider writes a prescription for an IV catheter and tells the nurse that a hypertonic IV solution will be prescribed. The nurse reviews the health care provider's prescription. Which hypertonic solution does the nurse expect to see prescribed by the health care provider? a) 0.9% normal saline solution (NS) b) 5% dextrose in water c) 0.45% NS d) 5% dextrose in 0.45% NS
d) 5% dextrose in 0.45% NS RATIONALE: A hypertonic solution is a solution that is more concentrated or has a greater osmolality than body fluids. Examples of hypertonic solutions include 5% dextrose in 0.45% saline solution, 5% dextrose in 0.9% NS solution, 3% saline solution, 5% saline solution, 10% dextrose in water, and 5% dextrose in lactated Ringer's solution. The usual choice for replacement of fluids lost through the gastrointestinal system is 5% dextrose in 0.45% saline solution. An isotonic solution is a solution with the same osmolality as body fluids; such a solution increases extracellular fluid volume. Examples are 0.9% normal saline solution and 5% dextrose in water. A hypotonic solution is a solution that is more dilute or has a lesser osmolality than body fluids. One example is 0.45% NS.
A pregnant client with preeclampsia is receiving an IV infusion of magnesium sulfate. Which medication, the antidote to magnesium sulfate, does the nurse ensure is readily available? a) Vitamin K b) Acetylcysteine c) Protamine sulfate d) Calcium gluconate
d) Calcium gluconate RATIONALE: Magnesium sulfate is a CNS depressant and anticonvulsant. It causes smooth muscle relaxation and is used to stop preterm labor to prevent preterm birth and prevent and control seizures in preeclamptic and eclamptic clients. Calcium gluconate, which acts as the antidote to magnesium, should be placed in the room of the client receiving magnesium sulfate. Vitamin K is the antidote to warfarin. Protamine sulfate is the antidote to heparin. Acetylcysteine is the antidote to acetaminophen.
The nurse suspects hyperglycemia in the client who is receiving parenteral nutrition (PN) if which signs/symptoms are noted? Select all that apply. a) Seizures b) Sweating c) Diaphoresis d) Excessive thirst e) Increased urine output f) Kussmaul respirations
d) Excessive thirst e) Increased urine output f) Kussmaul respirations RATIONALE: The high concentration of glucose in PN puts the client at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul respirations, diuresis, and, in severe cases, coma. If a client presents with these symptoms, the blood glucose level should be checked immediately. Seizures, sweating, and diaphoresis are signs of hypoglycemia.
The nurse asks Helena whether she has ever received a blood transfusion. Helena tells the nurse that she had one transfusion years ago but that "they had to stop it because I got the chills and a rash all over my body." After gathering additional information from Helena, the nurse reports the findings to the health care provider. The health care provider prescribes premedication with intravenous (IV) diphenhydramine hydrochloride. When does the nurse plan to administer the diphenhydramine hydrochloride? a) 1 hour before the transfusion is started b) 15 minutes after the transfusion is started c) 30 minutes before the transfusion is started d) Immediately before the transfusion is started
d) Immediately before the transfusion is started RATIONALE: A history of an allergic reaction may warrant the administration of an antihistamine such as diphenhydramine hydrochloride. IV medication should be given immediately before the transfusion is started. If an oral medication is prescribed, it should be administered 30 minutes before the transfusion is started. Administering the medication after the infusion has been started will make the medication less effective in reducing the risk of a transfusion reaction.
A client has been given instructions regarding the recently prescribed levothyroxine. The nurse determines the teaching was effective if the client states the medication should be taken in which manner? a) With food b) At bedtime c) With a snack at 3 p.m. d) In the morning, on an empty stomach
d) In the morning, on an empty stomach RATIONALE: Levothyroxine should be taken on an empty stomach to enhance its absorption. The daily dose should be taken in the morning, 1 hour before breakfast. Therefore, the remaining options are incorrect.
The nurse is monitoring a client who is receiving IV fluids through a central line inserted into the subclavian vein. The client suddenly complains of chest pain and difficulty breathing. The nurse notes that the client's pulse rate has increased, that the client is hypotensive, and that a loud churning sound is audible on auscultation over the precordium. The nurse suspects air embolism. Which immediate action should the nurse take? a) Removing the IV catheter b) Calling the resuscitation team c) Elevating the head of the client's bed d) Placing the client in left lateral Trendelenburg position
d) Placing the client in left lateral Trendelenburg position RATIONALE: Air embolism occurs when air enters the central venous system during catheter insertion, tubing changes, or breakage of the catheter. Signs include chest pain, tachycardia, dyspnea, hypotension, cyanosis, and a decreased level of consciousness. A loud churning sound may be heard over the precordium, a result of air in the right ventricle. If air embolism occurs, the nurse immediately clamps the catheter (but does not remove it), places the client in the left lateral Trendelenburg position to trap the air in the right atrium, and notifies the health care provider. There is no information in the question to indicate that the resuscitation team should be called.
After the transfusion reaction, the nurse tells Helena that a urine specimen must be obtained and sent to the laboratory for testing. Helena asks the nurse what the urine is being tested for. What does the nurse tell Helena? a) Protein b) Bacteria c) The presence of white blood cells (WBCs) d) The breakdown of red blood cells (RBCs)
d) The breakdown of red blood cells (RBCs)
A client with breast cancer who has undergone a mastectomy will be receiving chemotherapy. The oncologist prescribes allopurinol, 100 mg orally daily, to be started before the initiation of chemotherapy. The nurse should tell the client that this medication is used for which purpose? a) To prevent nausea b) To prevent diarrhea c) To reduce postoperative incision pain d) To minimize an increase in the plasma uric acid level
d) To minimize an increase in the plasma uric acid level RATIONALE: Allopurinol is used to reduce the blood level of uric acid. The level of uric acid increases as a result of the breakdown of DNA that occurs after chemotherapy-induced cell death. As a means of minimizing any increase in the plasma level of uric acid, allopurinol should be administered before the start of chemotherapy. Allopurinol does not prevent nausea or diarrhea or reduce incision pain.