nclex rn qbank princeton review

The nurse working in an intensive care unit is caring for a client diagnosed with acute angina. The client is receiving an intravenous infusion of nitroglycerin. What is the priority assessment for this client? A Neurologic status B Heart rate C Urine output D Blood pressure

Blood pressure Rationale: Nitroglycerin (NTG) is a vasodilator used to promote myocardial tissue perfusion and relieve chest pain associated with coronary artery occlusion. The systemic vasodilation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure should be evaluated every 15 minutes until stable, and then every 30 minutes to every hour thereafter. Clients receiving IV nitroglycerin should also be placed on continuous ECG monitoring. NTG is not known to affect neurologic status, urine output or heart rate.

The nurse on a cardiac unit is caring for a client who is receiving nitroglycerin intravenously for unstable angina. During administration of the medication, which assessment is the priority? A Cardiac enzymes B Respiratory rate C Cardiac rhythm D Blood pressure

Blood pressure Rationale: Nitroglycerin is a drug that is used to provide relief from myocardial chest pain and treat hypertensive emergencies. Nitroglycerin causes vasodilation. Common adverse effects of nitroglycerin include hypotension, headache and dizziness; therefore, monitoring the client's blood pressure is the priority. Nitroglycerin does not affect respirations, cardiac enzyme levels or heart rhythm.

A nurse is assessing a client who started taking prescribed olmesartan 2 weeks ago. Which finding indicates an expected response to the medication? Heart rate of 85 beats/min Urinary output of 45 ml/hr Blood pressure of 125/79 mmHg Respiratory rate of 20 breaths/min

Blood pressure of 125/79 mmHg Rationale: Olmesartan is an angiotensin II receptor antagonist used in the treatment of hypertension. The expected outcome is to maintain the blood pressure within normal limits. Although within normal limits, the heart rate, urinary output, and respiratory rate are not used to evaluate the efficacy of olmesartan.

A client is prescribed digoxin 0.25 mg by mouth daily. The health care provider has written a new order to give metoprolol tartrate 25 mg twice a day by mouth. In assessing the client prior to administering the medications, which finding should the nurse report to the health care provider? A Respiratory rate of 16 B Heart rate of 76 BPM C Urine output of 50 mL/hour D Blood pressure of 94/60

Blood pressure of 94/60 Rationale: Both medications decrease the heart rate. Metoprolol (Lopressor) affects blood pressure. Therefore, the heart rate and blood pressure must be within the normal range (HR 60 to 100 BPM and systolic BP greater than 100 mmHg) in order to safely administer both medications.

A client is being treated with long-term, low-dose glucocorticoids for an autoimmune disorder. Which physical change should the nurse expect to see with this client? A Jaundice B Hirsutism C Ascites D Buffalo hump

Buffalo hump Rationale: Long-term use of glucocorticoids can lead to Cushing's syndrome. Physical changes with Cushing's include weight gain, increased blood glucose, acne, thinning of the skin, easy bruising, and changes in body shape, such as a hump behind the shoulders due to the accumulation of fat on the back of the neck. This is commonly referred to as a "'buffalo hump". Jaundice, hirsutism, and ascites are not typically seen with long-term corticosteroid/glucocorticoid therapy.

The nurse is caring for a client who needs IV insertion. The client expresses concern about pain during the insertion. Which statement is the best response by the nurse? A "Don't worry; the needle is small." B "The pain is necessary but only last a few seconds." C "I will provide you with a distraction, so you will not feel it." D "A small amount of pain is expected but is not ongoing after the insertion."

"A small amount of pain is expected but is not ongoing after the insertion." Rationale: When preparing a client for peripheral IV insertion, the nurse should advise the client on what to expect including feeling some discomfort. Telling the client that the needle is small dismisses if the client feels any pain. Distractions can aid a client to focus on something besides the pain but do not indicate that pain will not be felt.

A nurse is providing education on the use of subcutaneous octreotide to a client who will be administering the medication at home. What will the nurse include in the teaching? "Store any remaining medication at room temperature." "Inject the medication into the gluteal area." "Administer the medication between meals." "Use the medication immediately after removing it from the refrigerator."

"Administer the medication between meals." Rationale: Side effects of octreotide include abdominal pain, ileus, and diarrhea. The client should be instructed to administer the medication between meals to decrease gastrointestinal effects. Unused medication should be discarded. The prescription is for a subcutaneous injection. The gluteal area is indicated for intramuscular injections. The medication should be allowed to reach room temperature before administration to decrease skin reactions at the injection site.

The nurse is reviewing medication safety with a client. Which statements by the client indicate a need for additional teaching? Select all that apply. "Alcohol is safe to drink with my medication." "I should take the medication as ordered." "I need to call my doctor if I have an allergic reaction." "It will be safe to take vitamins and herbal supplements with the medication." "If I miss a dose, I can double up the next dose." "My diet will not affect the medication."

"Alcohol is safe to drink with my medication." "It will be safe to take vitamins and herbal supplements with the medication." "If I miss a dose, I can double up the next dose." "My diet will not affect the medication." Rationale: Medication safety includes a number of concepts that the nurse should reinforce with the client. Current medications and allergies should be reviewed for potential interactions. Medications should be taken as prescribed without changing the dose or frequency. If a dose is missed, the client should avoid doubling up doses. Dietary choices, vitamins, herbal supplements, and alcoholic beverages should be reviewed for potentially causing adverse reactions or side effects. If an adverse reaction might occur, the client will need to make lifestyle changes. The client should notify the health care provider (HCP) if allergic reactions arise because the medication will need to be stopped.

The nurse is preparing a laboring client for placement of epidural analgesia. Which statement by the nurse is appropriate to include in the client education? "An epidural might cause a decrease in blood pressure." "An epidural will slow down your labor." "An epidural increases your risk of cesarean section." "An epidural allows your body to have more effective contractions."

"An epidural might cause a decrease in blood pressure." Rationale: One of the more common adverse effects of an epidural is maternal hypotension. This should be explained to the client prior to epidural placement. An epidural does not affect contraction frequency or strength and does not increase the risk of cesarean section

A nurse is providing dietary instructions to a client who is taking prescribed amiloride. Which information will the nurse include in the teaching? "Avoid eating foods that are rich in potassium such as bananas." "It is important to control high-sodium foods such as canned soups." "Eat plenty of foods that contain calcium such as milk." "Choose foods that are high in iron content such as shellfish.

"Avoid eating foods that are rich in potassium such as bananas." Rationale: Amiloride is a potassium-sparing diuretic used in the treatment of edema, hypertension, and potassium loss caused by other diuretic medications. Amiloride may cause hyperkalemia, so the client should be informed to limit their potassium intake. Sodium, calcium, and iron are not affected by the use of amiloride.

A nurse is providing education on the use of carbidopa/levodopa to a client with Parkinson's disease. What will the nurse include in the teaching? "This medication will stop the progression of your condition." "Notify your healthcare provider if your urine appears dark." "Eat plenty of whole-grain foods when taking this medication." "Avoid eating meals that are high in protein."

"Avoid eating meals that are high in protein." Rationale: Carbidopa/levodopa is a combination medication used in the management of Parkinson's disease. Consuming high-protein meals can impair the effects of levodopa. The nurse should instruct the client to eat protein in small portions. Carbidopa/levodopa does not halt the progression of Parkinson's disease. The medication is intended to reduce the symptoms associated with the condition. Darkening of bodily fluids can occur when taking the medication. However, the client should be informed this is not a harmful side effect. Whole grains contain pyridoxine, a vitamin that interferes with the effects of levodopa.

The nurse is collecting the health history from a client with depression who is taking prescribed phenelzine. Which statement would be appropriate for the nurse to make? "How often do you exercise in a week?" "Do you drink a lot of water?" "Can you describe the types of foods you eat?" "When was the last time you had blood work done?"

"Can you describe the types of foods you eat?" Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI), which is a medication used to treat depression when other drug classes are not effective. MAOIs are contraindicated with foods that contain tyramine, which can cause severe hypertension and tachycardia. Foods such as aged cheeses, smoked meats, and dried fruits contain tyramine. A client taking lithium is at risk for electrolyte imbalance and should be evaluated for exercise, blood work, and drinking water.

The nurse is completing a client's medication reconciliation. Which of the following questions by the nurse is necessary to ask the client during this process? "Can you provide the dosage of these medications?" "Do you experience any side effects when taking these?" "How long have you been taking these medications?" "Where do you store your medications?"

"Can you provide the dosage of these medications?" Rationale: The medication reconciliation should include the name of the medication(s), the dose, the frequency, and compliance to prescribed medication regimen. Side effects, history of prescription, and medication storage are not included as a part of the medication reconciliation.

The triage nurse at a health clinic receives a call from a client. The client states that they have been experiencing flu-like symptoms for the past 24 hours. The client asks for a prescription for zanamivir. How should the triage nurse respond? A "We will call your pharmacy for an antibiotic prescription for you." B "Do you have trouble swallowing big pills?" C "Call back tomorrow when you are sure you have the flu." D "Come in right away so we can start treating you."

"Come in right away so we can start treating you." Rationale: Antiviral influenza treatment with zanamivir should be initiated within 48 hours of onset of symptoms, thus it is important to get treatment started as soon as possible. The medication won't cure the disease, it will only shorten the time frame that someone is sick and may reduce the severity of the illness. It is administered by oral inhalation. Antibiotics are not an appropriate treatment for the flu.

A nurse has administered oral radioactive iodine to a client with thyroid cancer. What instructions will the nurse provide to the client upon discharge? "Do not share utensils with your family members." "Remain isolated until instructed by your healthcare provider." "Limit your fluid intake for the first several days." "Use a bedside commode for your elimination needs."

"Do not share utensils with your family members." Rationale: Radioactive medications such as iodine remain active until the substance decays. It is important to advise the client to not share food utensils as secretions are radioactive and can be transmitted to another person. The client does not need to be isolated. The nurse should instruct the client to maintain a 6-foot distance from others. Fluid intake should be increased after taking radioactive iodine to aid in waste removal. Bodily fluids and secretions remain radioactive and should be disposed of properly. Using a bedside commode increases the risk of transmission to others.

A client who previously had a stroke and is refusing to take the daily aspirin prescribed by their health care provider. Which statements should the nurse include in her response to the client? Select all that apply. "Do you experience any nausea when you take the aspirin?" "If you don't take aspirin every day, you might die." "Do you take your other medications as prescribed by your provider?" "Would you like to take the aspirin at another time of day?" "Can you tell me what concerns you have about the aspirin?"

"Do you experience any nausea when you take the aspirin?" "Do you take your other medications as prescribed by your provider?" "Would you like to take the aspirin at another time of day?" "Can you tell me what concerns you have about the aspirin?" Rationale: Although clients have the right to refuse medications, the nurse should still try to determine the underlying reasons for the client's refusal. Aspirin is a platelet aggregate inhibitor that is often prescribed for clients with cardiovascular disease (CVD) and stroke to prevent another thrombotic event and future stroke. Aspirin can cause gastrointestinal (GI) irritation and should be taken with food. The nurse can increase the client's adherence to their prescribed medication regimen by investigating their reasons for refusal, exploring any misconceptions about the drug and reinforcing the importance of the medication in preventing another stroke. In addition, involving the client in making decisions about when to take the medication can help the client accept the regimen. Stating that the client might die if they do not take the medication is nontherapeutic, inappropriate and violates the client's right to autonomy.

The nurse is preparing to administer methylergonovine to a client for postpartum hemorrhage. Which of the following questions by the nurse is appropriate to assess for contraindications before administration? "How many pregnancies have you had?" "Have you ever had uterine surgeries?" "Did you have asthma as a child?" "Do you have a history of high blood pressure?"

"Do you have a history of high blood pressure?" Rationale: The nurse should assess for any history of hypertension, hypotension, or preeclampsia before administration because these are contraindications to methylergonovine. Asthma is not a contraindication for this medication. The number of pregnancies or uterine surgeries does not have any effect on the ability to administer this medication.

A client who is taking duloxetine asks the nurse if the medication treats depression or diabetes. Which is the best response from the nurse? A "Duloxetine is used to treat depression but can also be used to lower blood sugar levels." B "Duloxetine is not prescribed for either depression or diabetes." C "Duloxetine is used to treat diabetes but can also be used to treat depression." D "Duloxetine is used to treat depression but can be used to treat pain that can occur in people with diabetes."

"Duloxetine is used to treat depression but can be used to treat pain that can occur in people with diabetes." Rationale: Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) that can be used to treat depression but also can be used to treat pain associated with diabetic neuropathy. Duloxetine is not used to lower blood glucose levels. While it is a true statement that duloxetine is an antidepressant, it is not the best response from the nurse since it does not fully address the client's question. The best response is to confirm the use of duloxetine in the treatment of depression and to explain its additional role in treating diabetic neuropathy in some situations.

A client is started on long-term corticosteroid therapy for an autoimmune disorder. Which statement by the client indicates the need for more teaching by the nurse? A "I will be sure to eat foods that are high in potassium." B "I will keep a record of my weight each week." C "The medication needs to be taken with food." D "For 1 week each month I will stop taking the medication."

"For 1 week each month I will stop taking the medication." Rationale: Corticosteroids should never be stopped abruptly, they should always be weaned. To suddenly stop this medication may result in a sudden drop in the blood pressure from a loss in fluid volume associated with adrenal crisis. Clients should be warned not to abruptly stop taking the medication. Corticosteroids can lower the amount of potassium in the body so the client should eat more potassium rich foods. Weight gain is an expected effect of corticosteroid therapy. Clients should regularly keep track of their weight. Generally, corticosteroid medications are taken with breakfast.

The nurse has attended a staff training program about nursing roles during disasters. Which of the following statements by the nurse indicates the need for further training? "Nurses may be responsible for activating notification systems to call in nurses who are not scheduled to work." "General staff nurses should be assigned to perform triage for incoming clients to determine level of severity of injuries." "Critical care nurses should be prepared to determine clients who are stable enough for transfer to ensure adequate beds for critically ill clients." "Administrative nurses may have roles reassigned to provide care for stable clients on the unit."

"General staff nurses should be assigned to perform triage for incoming clients to determine level of severity of injuries." Rationale: Mass casualty events such as disasters require nurses to assume roles outside of normal daily operations. Typically, general staff nurses will be assigned to discharge stable clients or care for stable clients in the emergency department to allow emergency department nurses to perform triage and critical care duties as needed for disaster victims. Nurses should be prepared to activate notification systems to increase nursing staff available to care for victims. Critical care nurses should discharge stable clients to medical-surgical units to allow for space for victims who are unstable. Administrative nurses may be reassigned outside of their regular roles to care for stable clients with predictable outcomes.

The nurse is caring for a female client who is requesting hormonal contraceptives. Which of the following questions should the nurse ask to assess for contraindications? "Have you ever had a blood clot?" "How many children do you have?" "Do you drink alcohol?" "Did you experience acne in adolescence?"

"Have you ever had a blood clot?" Rationale: A history of thromboembolic disorders is a contraindication to hormonal contraceptives; therefore, any history of thrombus should be assessed. The number of children/pregnancies and use of alcohol are probable history questions but are not contraindications to this method. Acne is a side effect of oral contraceptives but not a contraindication.

The nurse is performing a follow-up assessment for a client who received methylprostaglandin postpartum. Which question would be appropriate for the nurse to ask when assessing the client for side effects? "Have you noticed if the bleeding has decreased?" "Do your breasts feel engorged?" "Are you having any pain?" "Have you experienced any diarrhea?"

"Have you experienced any diarrhea?" Rationale: Methylprostaglandin is a medication used to treat postpartum bleeding. A common side effect of methylprostaglandin is diarrhea. Asking if the bleeding has decreased would assess the effectiveness of the medication. Engorged breasts and pain are normal findings in postpartum women and are not associated with methylprostaglandin.

The nurse is assessing a client who reports urticaria on the chest and abdomen. Which question would be most appropriate for the nurse to ask? "Have you recently started taking any new medications?" "Do you have a family history of psoriasis?" "How much water do you drink each day?" "Has anyone in your home been sick?"

"Have you recently started taking any new medications?" Rationale: Allergic reactions to medications can happen immediately but may take hours or days to have visible signs or symptoms. It is important for the nurse to ask the client if they have taken any new medications and if they have, to ask about the frequency of that medication. Drinking water is important to prevent dry skin; however, urticaria, or hives, occurs with allergic reactions. A family history of psoriasis would be appropriate to assess if the client is reporting a rash that appears like plaques. Assessing if anyone in the home has been sick is appropriate if the client has a contagious condition, like scabies.

A nurse is providing education to a client about newly prescribed diltiazem. Which statement will the nurse include in the teaching? "Skip the dose if your systolic blood pressure is less than 120 mmHg." "Hold the dose if your heart rate is less than 50 beats/min." "Call your healthcare provider if you experience any fever." "Notify your healthcare provider if you notice any weight loss."

"Hold the dose if your heart rate is less than 50 beats/min." Rationale: Diltiazem is a calcium channel blocker medication used in the treatment of hypertension and cardiac arrhythmias such as atrial flutter and fibrillation. Diltiazem can cause bradycardia. The nurse should instruct the client how to take their pulse and hold the dose if less than 50 beats/min. Diltiazem should be held if the systolic blood pressure is below 90 mmHg. Fever and weight loss are not effects associated with the use of diltiazem.

The nurse is teaching a client who is pregnant about the prescribed infusion of magnesium sulfate. Which statement by the nurse would be appropriate to include in client education about this medication? "You may experience an increase in contractions while taking this medication." "Vaginal bleeding is normal with this medication." "Hot flashes are a side effect of the medication." "You may feel the baby move more with this medication."

"Hot flashes are a side effect of the medication." Rationale: Magnesium sulfate infusion is used in pregnancy to prevent seizure due to preeclampsia. When teaching the client about side effects, the nurse should advise the client of hot flashes, feelings of warmth, and diaphoresis. Vaginal bleeding does not occur with magnesium and could indicate a complication of the pregnancy. Magnesium does not affect the movement of the baby or contractions.

The nurse is preparing to administer prescribed sertraline to a client with a history of depression. Which statement by the client would require immediate follow-up? "I noticed this medication gives me a dry mouth." "I would prefer to crush that medication." "I also take St. John's wort with that medication." "I typically take the medication at night."

"I also take St. John's wort with that medication." Rationale: Sertraline is a selective serotonin reuptake inhibitor, which treats depression by increasing the amount of available serotonin. St. John's wort enhances serotonin transmission and could cause an exacerbation of the effects of serotonin. Taking the medication at night or crushing the tablet does not increase the likelihood of a reaction. Dry mouth is a common side effect of the medication and is not the priority.

A nurse is assessing a client who takes prescribed oral indomethacin. Which client statement indicates an intended response to the medication? "My appetite is greater in the mornings." "I am able to rotate my wrists without pain." "I no longer have to urinate in the middle of the night." "My endurance while exercising has improved."

"I am able to rotate my wrists without pain." Rationale: Indomethacin is a non-steroidal anti-inflammatory medication used in the treatment of rheumatoid arthritis and other inflammatory disorders. The expected outcome is increased mobility of the joints without pain. Full range of motion without pain is an expected response. Improved appetite, decreased nocturia, and increased endurance are responses unrelated to the effects of indomethacin.

The nurse is assessing a pregnant client who has just received terbutaline for preterm labor. Which statement by the client would indicate to the nurse the client is experiencing an adverse effect of the medication? "I am feeling very nervous right now." "I think I am going to vomit." "I am no longer having contractions." "I can tell the baby is moving."

"I am feeling very nervous right now." Rationale: Terbutaline is a medication used to stop or delay preterm labor by preventing or slowing contractions. A client who is experiencing an adverse effect of terbutaline will report feeling nervous, shaking, and may have tremors. Vomiting and feeling the baby move are normal findings in pregnancy. The client who reports a decrease in contractions would indicate the medication is having a therapeutic effect.

The nurse is monitoring a client who received the first dose of penicillin for a systemic infection. Which statement by the client should indicate to the nurse that the client might be experiencing a severe allergic reaction? "I am developing a headache." "I feel like I can't breathe." "I have lost my appetite." "I think my blood sugar is low."

"I feel like I can't breathe." Rationale: If a client expresses that they are unable to breathe as they normally would, the nurse should be concerned about the possibility of an allergic reaction. Headaches are not a direct symptom of an allergic reaction. Clients who are taking antibiotics may report a change in appetite or bowel habits. Decreased blood sugar does not occur with allergic reactions.

The nurse is collecting a client's health history before administering oxytocin for induction of labor. Which of the following statements by the client is a contraindication? "This is my fourth baby." "I have a placenta previa." "My water broke an hour ago." "I have gestational diabetes."

"I have a placenta previa." Rationale: Placenta previa is a condition in which the placenta blocks the cervical opening; therefore, a vaginal delivery is contraindicated. The number of pregnancies and membrane status are not contraindications to oxytocin. Presence of certain medical conditions, such as gestational diabetes, are important to include in the client's history but are not contraindications.

The home health nurse is teaching a female client about self-administering vancomycin. Which statement by the client demonstrates understanding of the teaching? "I need to call my provider if my urine changes." "Muscle tingling and weakness is an expected side effect of this medication." "Ringing in the ears is common when taking vancomycin." "I should avoid eating food with active cultures in it."

"I need to call my provider if my urine changes." Rationale: Vancomycin is commonly linked to nephrotoxicity, leading to the need for monitoring trough levels. Signs of kidney injury include decreased urination, blood in the urine, and other changes in urine color and clarity. Antibiotic-associated diarrhea (colitis) results from oral or parenteral antibiotic therapy. Another pathogen is Candida albicans, which results in vaginal yeast infection and oral thrush. Probiotics can reduce these risks. Antibiotic-induced neuropathy is a rare complication of several antimicrobial agents. Hypokalemia can result from vancomycin; therefore, muscle weakness and numbness or tingling should be reported. Ototoxicity is a serious complication from vancomycin due to vestibular damage.

A nurse is assessing a client with hyperthyroidism and is taking prescribed methimazole. Which client statement indicates a therapeutic response to the medication? "My intolerance to cold has improved." "I no longer feel heart palpitations." "I don't get constipated as easily." "I have lost a few pounds."

"I no longer feel heart palpitations." Rationale: Methimazole is an antithyroid medication used in the treatment of hyperthyroidism. Tachycardia and heart palpitations are signs of hyperthyroidism. The expected response of methimazole is a decrease in the severity of hyperthyroidism symptoms. Intolerance to cold, constipation, and weight gain are signs of hypothyroidism. Improvement in these symptoms do not evaluate the effectiveness of methimazole.

A nurse has attended a conference about communicable diseases. Which statement by the nurse indicates the need for further teaching? "I only need to report diseases associated with children." "I should review the infection control policies." "I need to report suspected communicable disease to the infection control department." "I need to use the correct isolation precautions for the disease."

"I only need to report diseases associated with children." Rationale: The nurse should be aware of the infection control policies for their organization. The CDC recommends that all suspected communicable diseases be reported to the health department via the infectious disease department. Staff members need to use the appropriate infection control precautions for all communicable diseases. All communicable diseases need to be reported, not just those associated with children.

The nurse is providing teaching to a client who has been prescribed cyclophosphamide for breast cancer treatment. Which of the following statements made by the client would indicate that additional teaching is needed? A "I will probably need to plan on using a wig to cover my hair loss." B "I may have trouble getting pregnant due to the damaging effects of the medication." C "I will need to stay away from children when my white blood cell count is low." D "I should limit the amount of fluids I drink while taking this medication."

"I should limit the amount of fluids I drink while taking this medication." Rationale: Cyclophosphamide is a chemotherapeutic medication. Some of the side effects of this medication include hair loss, low white cell count and infertility. The client is encouraged to drink about 2 to 3 liters of fluid per day to aid in eliminating the chemotherapy from the body.

The nurse is caring for a client undergoing chemotherapy for colon cancer. Which of the following statements made by the client should the nurse be most concerned about? A "I pray several hours a day to God to help me deal with this cancer." B "I think the green tea I'm drinking is helping me to fight the cancer." C "I am using relaxation techniques to help cope with the stress of having cancer." D "I take 10 different types of vitamins daily to help my immune system fight the cancer."

"I take 10 different types of vitamins daily to help my immune system fight the cancer." Rationale: The client's statement of taking 10 different vitamins daily should be cause for concern. While other complementary and integrative health therapies may or may not have a direct beneficial effect on cancer, the multitude of vitamins may interfere with chemotherapeutic medications and may have toxic effects. The client should speak with their oncologist for further evaluation of the continuation of the vitamins.

The nurse is counseling a client with gastroesophageal reflux disease (GERD) who has been taking prescribed famotidine for two days. Which statement would require immediate follow up by a healthcare provider? "I take digoxin for my heart failure." "I use calcium carbonate if I have symptoms after meals." "I use alendronate for my osteoporosis." "I'm still having some symptoms of heartburn."

"I take digoxin for my heart failure." Rationale: Most medications for heartburn decrease stomach acid. Histamine blocking drugs such as famotidine (H2 receptor antagonist) are available as both prescription and over-the-counter. It is often advised to take an antacid with an H2RA to relieve pain. Symptoms should be improved after one week. Famotidine does not cause bone loss, unlike proton pump inhibitors, and is an acceptable choice for clients with osteoporosis. Famotidine is used cautiously in clients on digoxin as it decreases absorption. This client needs to have their digoxin level checked, and the dosage may need to be adjusted.

The nurse is caring for an older adult client with a history of epilepsy who is taking prescribed bupropion. Which of the following statements by the client should the nurse report to the health care provider? "I can sleep at night since I take this medication in the morning." "I chew gum for the dry mouth I get with this medication." "It helps when I take this medication with food." "I take my epilepsy medication with this medication every day."

"I take my epilepsy medication with this medication every day." Rationale: Administration of epileptic medications with bupropion is contraindicated because it increases the risk of seizures. Bupropion may be given with food to decrease gastrointestinal irritation. Gum or candy are recommended to help activate saliva and decrease symptoms of dry mouth. Taking bupropion in the morning decreases insomnia that may occur if taken in the evening.

The nurse is collecting the health history of a client who reports taking over-the-counter pseudoephedrine for nasal congestion. Which statement by the client would require follow-up by the nurse? "I take this medication at night before I go to bed." "I have to use a normal saline nasal spray since I started this medication." "I avoid drinking beverages with caffeine while taking the medication." "I chew gum when I take this medication to help with my dry mouth."

"I take this medication at night before I go to bed." Rationale: Pseudoephedrine is a nasal decongestion that causes vasoconstriction in the respiratory mucosa and bronchodilatation making it easier for the client to breathe. The medication is a stimulant, so clients should avoid taking the medication before bed to prevent insomnia. The use of caffeine will exacerbate the alpha-adrenergic effect of this drug. Chewing gum helps alleviate dry mouth that accompanies respiratory mucosa constriction that occurs when taking this medication. This medication can dry mucus membranes, so clients may use a normal saline nasal spray.

The nurse is providing discharge instructions to a client who is going home with a peripherally inserted central catheter (PICC). Which statement by the client indicates that teaching was effective? A "I will be sure to place my arm with the catheter in a sling during the day." B "I will change the catheter dressing at least daily." C "I will not drive while the catheter is in place." D "I will avoid carrying my child with the arm that has the catheter."

"I will avoid carrying my child with the arm that has the catheter." Rationale: A PICC is typically placed in the antecubital fossa or the basilic vein and allows the client considerable freedom of movement. The client will be able to drive but should avoid heavy lifting which can dislodge or occlude the catheter. Placing the arm in a sling and daily dressing changes are not necessary. Generally, a PICC dressing should be changed once a week or when it becomes wet, soiled or dislodged.

A nurse is providing education on activities of daily living to a client taking warfarin. Which statement made by the client indicates further teaching is required? "I will brush my teeth using a soft-bristled toothbrush." "I will wear a medical alert bracelet on my wrist." "I will be sure to consume plenty of green leafy vegetables." "I need to shave using an electric razor."

"I will be sure to consume plenty of green leafy vegetables." Rationale: Warfarin is an anticoagulant medication used in the treatment of blood clotting disorders. Green leafy vegetables contain a high amount of vitamin K, the antidote for warfarin. The client should be instructed to limit their intake of vitamin K-containing foods. Using a soft-bristled toothbrush and an electric razor decrease the risk of bleeding. A medical alert bracelet is necessary for clients who are on blood-thinning medications to alert first responders in case of an emergency.

A nurse is providing education on the use of pregabalin to a client with a seizure disorder. Which client statement indicates further teaching is required? "I will record the number of seizures I experience." "I will hold the dose if my seizures are controlled." "I will notify my healthcare provider if I have significant mood changes." "I will report any weight gain to my healthcare provider."

"I will hold the dose if my seizures are controlled." Rationale: Pregabalin is an anticonvulsant medication used to manage seizure disorders. The client should take the medication as prescribed as abrupt discontinuation can lead to seizure activity. Recording the number of seizures helps to evaluate the effectiveness of the medication. Pregabalin can cause suicidal thoughts and behaviors. The client should promptly report significant mood changes. Pregabalin can cause weight gain and peripheral edema. These side effects should be reported to the healthcare provider.

A nurse is educating a client on insulin administration. Which statement made by the client indicates further teaching is required? "I will inject the insulin in the same site every day." "The best injection area is around my abdomen." "I will squeeze my skin together to inject the medication." "Gentle pressure should be applied to the site after injection."

"I will inject the insulin in the same site every day." Rationale: The nurse should further educate the client on rotating injection sites to prevent lipohypertrophy. Lipohypertrophy is the development of scar tissue under the skin that prevents adequate absorption of the medication. The absorption rate is greater in the subcutaneous tissue of the abdomen. Squeezing or bunching the skin together ensures the medication is administered into the subcutaneous layer. Gentle pressure helps the medication to absorb better.

A client has been taking rosuvastatin for six weeks as part of a treatment plan to reduce hyperlipidemia. The clinic nurse is reviewing and reinforcing information about the medication with the client. Which statements by the client indicates an understanding about the medication? Select all that apply "I will need to come back to have my liver and kidney labs checked." "I need to be careful when I get up because this medication can make my blood pressure drop." "I will need to call my doctor if I have any muscle weakness or pain, especially in my legs." "This medication has to be taken first thing in the morning, before I eat breakfast." "I add some nuts and fresh fruit to my oatmeal in the morning and I can't remember when I last ate a steak."

"I will need to come back to have my liver and kidney labs checked." "I will need to call my doctor if I have any muscle weakness or pain, especially in my legs." "I add some nuts and fresh fruit to my oatmeal in the morning and I can't remember when I last ate a steak." Rationale: Clients taking rosuvastatin need to be monitored for alteration in liver function. An adverse effect of rosuvastatin is muscle pain and weakness (rhabdomyolysis). Left untreated, rhabdomyolysis can lead to renal impairment. The medication does not affect blood pressure or cause orthostatic hypotension. The client should be taught to follow a low-cholesterol diet, which includes increasing intake of whole grains and limiting intake of foods high in saturated fats, trans fats and dietary cholesterol. The medication is ordered once a day. The client can take it at any time of day, preferably at the same time of day each day, before or after eating.

A client has been prescribed alendronate for osteoporosis. Which statements indicate that the client understands how to safely take this medication? Select all that apply. "I will notify my doctor if I experience worsening heartburn." "I will swallow the pill with a full glass of water." "I will take the pill with an antacid to prevent stomach upset." "I will always eat breakfast before taking the pill." "I will stand or sit quietly for 30 minutes after taking the pill."

"I will notify my doctor if I experience worsening heartburn." "I will swallow the pill with a full glass of water." "I will stand or sit quietly for 30 minutes after taking the pill." Rationale: Alendronate is a bisphosphonate used to treat osteoporosis. It can cause esophagitis or esophageal ulcers unless precautions are followed. The client must sit upright or stand for at least 30 minutes after taking the medication. The client should take the medication with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. Antacids will interfere with absorption and should not be taken at the same time.

The nurse is teaching a client with diabetes about newly prescribed trimethoprim and sulfamethoxazole (TMP-SMX) to treat a urinary tract infection. Which statement by the client indicates understanding? "I will stop taking this medication if I develop a rash." "This antibiotic will kill mature bacteria in my urinary tract." "I should avoid dairy products when taking this medication." "My blood sugar will not be affected by this medication."

"I will stop taking this medication if I develop a rash." Rationale: TMP-SMX is a sulfonamide medication. These drugs are bacteriostatic and therefore, halt the multiplication of new bacteria, but do not kill mature bacteria. Clients using sulfonylureas for the management of diabetes should know that other sulfa drugs may increase the chances of hypoglycemia. The action of metformin is also enhanced. Dairy is avoided when clients are taking tetracyclines. TMP-SMX is the most common cause of erythema multiforme. Sulfonamides are also often implicated in cases of both toxic epidermal necrosis and Stevens-Johnson syndrome, which can be fatal.

The nurse is evaluating a client post kidney transplant about the client's understanding of mycophenolate mofetil. Which statement by the client indicates a need for further teaching? A "I will take the medication on an empty stomach." B "I will notify my doctor when I develop a sore throat and chills." C "I will take Tylenol for minor aches and pains." D "I will take milk of magnesia with it to prevent heartburn."

"I will take milk of magnesia with it to prevent heartburn." Rationale: Mycophenolate mofetil is a medication used to prevent transplant organ rejection. Absorption of this medication can be decreased by antacids that contain magnesium and aluminum hydroxides such as milk of magnesia. Accordingly, mycophenolate mofetil should not be given simultaneously with these drugs. Taking acetaminophen (Tylenol) for minor pain is acceptable, as long as the client remains within the FDA-recommended maximum daily dose of 3,900 mg. A sore throat and chills can be early symptoms of an infection in immunosuppressed clients, so the client should notify their HCP. Taking the drug on an empty stomach will facilitate complete absorption and is recommended.

The nurse is reviewing discharge instructions with the parent of a 3-year-old client who was admitted for poisoning after ingesting cherry-flavored acetaminophen. Which statement by the parent would require follow up by the nurse? A "I should use non-flavored medications." "I will reach out to the poison control center if this happens again." "I will use ipecac syrup to induce vomiting." "I will have all medications in a locked cabinet."

"I will use ipecac syrup to induce vomiting." Rationale: Accidental ingestions (poisoning) are the most frequent accident in toddlers. Therefore, it is imperative to focus on keeping all poisonous substances, drugs, and small objects securely out of the reach of children and medications in a locked cabinet. Parents should be instructed to call the poison control center in case of accidental ingestion and to have the number listed on their cell phone. Since 2003, the American Academy of Pediatrics has discouraged the use of syrup of ipecac to induce vomiting after accidental ingestion. Instead, families should call the poison control center immediately. Using non-flavored medications will decrease the likelihood the child will consume a large amount; it does not prevent the ingestion of the medication or determine what should be done after accidental ingestion.

The nurse is educating a client with end stage chronic obstructive pulmonary disease (COPD) about medication management. Which statement by the client indicates an understanding of the teaching? "I will use the albuterol in the nebulizer before my other inhalers each morning." "I can use my tiotropium inhaler if I get short of breath." "I will only use the fluticasone inhaler on the days I am really out of breath." "The side effects of these medications will be less severe because I'm not taking them by mouth."

"I will use the albuterol in the nebulizer before my other inhalers each morning." Rationale: Medication regimens used to treat COPD are based on disease severity. For grade III or IV (severe and very severe) COPD, medication therapy includes treatment with one or more bronchodilators and inhaled corticosteroids. Clients with COPD experience significant breathlessness and reduced FEV1 upon waking. Use of nebulized albuterol prior to administration of long-acting medications relaxes the airway and allows other medications to get deeper into the lungs. Tiotropium is a long-acting anticholinergic (muscarinic) and is not meant for rescue purposes. Fluticasone prevents inflammation and therefore, must be used every day. Clients with COPD will experience side effects of the medications due to the long duration of use.

The nurse has provided instructions to a client on the use of warfarin. Which statement by the client requires further teaching? A "If I catch a cold, I will use guaifenesin to make my cough better" B "If I develop an itchy rash, I will use a cream with diphenhydramine." C "If I become constipated, I can take laxatives containing magnesium salts." D "If I develop a headache, I should take ibuprofen to help my pain."

"If I develop a headache, I should take ibuprofen to help my pain." Rationale: Warfarin is an anticoagulant that prolongs bleeding time and is used to treat and prevent blood clots. One of the most serious side effects of warfarin is excessive bleeding and hemorrhage. Warfarin interacts with a number of other drugs. Clients taking warfarin should not take nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen at the same time due to an increased risk for bleeding. There are no known drug interactions between warfarin and laxatives containing magnesium salts, guaifenesin, or diphenhydramine cream. As a result, they may be taken together.

The health care provider writes a new order for a fentanyl patch to manage chronic pain experienced by a client in hospice care. The nurse is teaching the client and family members about the fentanyl patch and knows that teaching was effective when the client makes which of the following statements? Select all that apply. "I can soak in a hot tub to help decrease my pain." "If my pain is too great while I am on the patch, I can take a supplemental pain medication." "I should cut up the patch before I throw it away so no one else can use it." "It may take up to a half day or longer for the patch to start working the first time I use it." "I will take the old patch off before I apply the new patch on."

"If my pain is too great while I am on the patch, I can take a supplemental pain medication." "It may take up to a half day or longer for the patch to start working the first time I use it." "I will take the old patch off before I apply the new patch on." Rationale: Fentanyl patches are slowly absorbed via the subcutaneous tissue at a predetermined rate for up to 72 hours. Due to the slow absorption rate, the first patch may take 12 to 24 hours before effective analgesia is felt; a short-acting opioid may be given for breakthrough pain. The client can shower or bathe with the patch, but it should not be exposed to heat (hot tubs, heating pads) because it speeds up the absorption of the medication. Old patches are removed and the new patch is applied to a different skin area. Old patches are disposed of by folding the old patch in half, not by cutting them up and throwing them in the trash (which may be dangerous for people and pets).

A nurse is providing discharge instructions on the use of an EpiPen to a client with a severe food allergy. Which statement will the nurse include in the teaching? "Remove the autoinjector immediately after administering the medication." "Inject the medication into your outer thigh." "Do not massage the area after injecting the medication." "The medication needs to be injected into bare skin."

"Inject the medication into your outer thigh." Rationale: Epinephrine supplied as an EpiPen should be administered into the outer thigh. The thigh has a rich supply of blood and helps to promote medication absorption. The autoinjector should remain in place for 10 seconds before removing it from the thigh. The injection site should be massaged for 10 seconds after administration to decrease tissue irritation. The EpiPen may be administered over clothing if necessary.

A nurse is assessing a client who was prescribed fluoxetine for panic disorder 5 days ago. The client tells the nurse their symptoms are not improving. Which statement will the nurse make to the client? "It might be a few more weeks before your symptoms improve." "I will contact the healthcare provider to increase your dose." "Have you been taking the medication as directed?" "Why do you feel your symptoms are not improving?"

"It might be a few more weeks before your symptoms improve." Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of anxiety and panic disorders. SSRIs can take between 1 to 4 weeks to exert their effects. The nurse should educate the client on the onset of fluoxetine. The client has not been taking the medication long enough to warrant an increase in the dose. Asking the client if they have been taking the medication as directed does not address their concerns. "Why" questions do not promote therapeutic communication and do not address the client's concern.

A nurse is administering vincristine to a client with cancer. The client asks the nurse how the medication works. Which statement by the nurse is appropriate? "It stops the synthesis of proteins in cancer cells." "It prevents cell division of cancer cells." "It interrupts the S-phase of cancer cell reproduction." "It alters the DNA structure of cancer cells."

"It prevents cell division of cancer cells." Rationale: Antimitotics, such as vincristine, kill cancerous cells by inhibiting cell division and mitosis. Stopping the synthesis of proteins in cancer cells is the expected action of antitumor antibiotics. Interruption of the S-phase of cell reproduction is the expected action of antimetabolites. Altering the DNA structure of cancer cells is the expected action of alkylating agents.

The daughter of a client with Alzheimer's disease asks the nurse, "Will the medication my mother is taking cure her dementia?" What is the best response by the nurse? A "It will not improve dementia but can help control emotional responses." "It will help your mother live independently again." C "It is used to halt the progression of Alzheimer's disease." "It will provide a steady improvement in memory."

"It will not improve dementia but can help control emotional responses." Rationale: Drug therapy for Alzheimer's disease such as memantine and donepezil produce modest improvements in cognition, behavior, and function, and slightly delayed disease progression. They do not reverse the dementia or halt the progression of Alzheimer's disease. At best, drugs currently in use may slow loss of memory and improve cognitive functions (e.g., memory, thought, reasoning) and emotional lability. However, these improvements are modest and last a short time and for many clients, even these modest goals are elusive.

The nurse is educating a client who has diabetes mellitus on home safety. Which of the following statements by the nurse is appropriate? "Store used needles for later use." "Keep a spare vial of insulin in the refrigerator." "You don't need to check your glucose if your diabetes is well-controlled." "Don't wear shoes while inside your home."

"Keep a spare vial of insulin in the refrigerator." Rationale: Having a backup vial of insulin in the refrigerator is a safe practice if the current vial becomes lost or damaged. Used needles should be discarded in a sharp-safe container. Glucose levels are important to assess regardless of how well the client's condition is controlled. The client should wear well-fitting shoes as often as possible, even indoors, to prevent foot injury.

The nurse is teaching a client who is postoperative cesarean section about prescribing morphine via a patient-controlled device. Which statement should the nurse include in client teaching about the medication? "It is normal for this medication to cause burning at the IV site." "You will probably experience some itching each time you administer a dose." "Tell your family members to press the administration button if you are feeling tired." "Let a staff member know if you experience any trouble breathing."

"Let a staff member know if you experience any trouble breathing." Rationale: Opioids, such as morphine, are used to treat postoperative pain. A patient-controlled device allows the client to administer the medication at prescheduled intervals. Opioids can cause respiratory depression. When teaching about the patient-controlled device, the nurse should instruct the client to report any changes in respiratory status, including shortness of breath. Only the client should push the administration button for the device. Burning at the IV site and reports of itching are not normal findings and should be reported.

The nurse is monitoring a client who received the first dose of a newly prescribed medication. Which statement by the client would require immediate follow up by the nurse? "My pain is the same." "My throat feels scratchy." "I need to go to the bathroom." "I would like a glass of water."

"My throat feels scratchy." Rationale: The client who is having a systemic allergic reaction may experience swelling or itching of the throat after administration of the medication. A pain level that is unchanged, thirst, or the need to void does not indicate an allergic reaction.

A nurse is providing discharge education on the use of sustained-release procainamide to a client with newly diagnosed atrial flutter. What will the nurse include in the teaching? "You will need to have laboratory blood tests performed every 3 months." "Hold the medication if your heart rate is below 70 beats/min." "Notify your healthcare provider if you begin experiencing joint pain." "Crush your medication and mix it with food to mask the taste."

"Notify your healthcare provider if you begin experiencing joint pain" Rationale: Procainamide is an antiarrhythmic medication used in the management of atrial flutter. One of the adverse effects of procainamide is systemic lupus syndrome characterized by fever and painful joints. The client should be instructed to notify the healthcare provider of any adverse symptoms. Lab tests need to be conducted frequently (every week) at the start of therapy to monitor complete blood counts and procainamide blood levels. Procainamide does not have a direct effect on heart rate. Sustained-release medications should not be crushed or chewed.

The nurse is educating the client with third degree burns who has been prescribed total parenteral nutrition (TPN). The client has not tolerated enteral feedings. Which statements should be included in the teaching? "Parenteral nutrition will help with wound healing." "This type of nutrition is administered through a short catheter in your arm." "The bag and tubing will be changed every other day." "Your electrolyte levels and blood sugar will not be affected by this type of nutrition."

"Parenteral nutrition will help with wound healing." Rationale: TPN provides calories; restores nitrogen balance; and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. TPN can also promote tissue and wound healing and normal metabolic function. Potential complications include complications related to the use of central venous access devices, infection and sepsis, hyperglycemia or hypoglycemia, fluid and electrolyte, and acid-base imbalances, phlebitis, hyperlipidemia, and liver and gallbladder disease. Infusion administration sets should include an in-line filter and are changed every 24 hours.

The nurse has attended a staff education conference about electrical safety in the healthcare setting. Which of the following statements by the nurse indicates the need for further teaching? "Plugs should be removed from the wall outlet by pulling from the cord." "All electrical equipment should be checked for fraying or other signs of damage before use." "Electrical equipment should not be used near wet areas such as sinks and showers." "Electrical cords should be kept coiled or taped to the ground to prevent damage and tripping hazards."

"Plugs should be removed from the wall outlet by pulling from the cord." Rationale: It indicates a correct understanding of electrical safety if the nurse states that cords should be kept coiled or taped to the ground to prevent tripping and damage to the cords, to avoid the use of electrical equipment around wet areas since water is an electrical conductor, and to check cords for fraying and signs of damage, which could increase the risk of electrical shock to the user. Plugs should be removed from the wall outlet by pulling from the plug, not the cord, as this could cause damage to both the outlet and the device, increasing the risk of electrical shock.

The nurse is administering docusate sodium to a postpartum client. Which of the following should the nurse include in the medication teaching? "This medication will help with your uterine cramping." "Breastfeeding is contraindicated while taking this medication." "Report to the healthcare provider if you experience diarrhea." "This medication lowers your risk of hemorrhage."

"Report to the healthcare provider if you experience diarrhea." Rationale: Docusate sodium is a stool softener/laxative and should not be administered to a client who is experiencing diarrhea. This medication does not directly affect breastfeeding or the risk of hemorrhage. Docusate sodium does not affect uterine cramping.

The nurse is providing medication teaching for a client who has been prescribed tetracycline. The client regularly takes calcium supplements to prevent osteoporosis. Which statement is appropriate for the nurse to make? "Take your calcium two hours before you take the antibiotic." "You can take the calcium with the antibiotic to decrease an upset stomach." "Try taking the antibiotic and calcium with orange juice." "It is best to take the antibiotic and calcium on an empty stomach."

"Take your calcium two hours before you take the antibiotic." Rationale: All tetracycline derivatives are bacteriostatics, and their concentration in serum should not fall during the therapy below the generally accepted minimum therapeutic concentration. Tetracyclines have a high affinity to form chelates with iron, aluminum, magnesium, and calcium. These complexes are poorly absorbed in the gastrointestinal tract; therefore, an interval between the ingestion of tetracyclines and cations is necessary. Taking tetracyclines with orange juice may increase irritation because the medication itself is also acidic. Additionally, orange juice may have added calcium, which would interact with the antibiotic. It is okay to take tetracyclines with food as long as it doesn't contain dairy. This may reduce stomach-related side effects.

The nurse is collecting the health history of a client with heart disease who reports experiencing episodes of diarrhea. The client reports taking loperamide at home. Which of the following statements should the nurse make? "Taking this medication may increase your risk of an abnormal heart rhythm." "It is safe to drink alcohol while using this medication." "Using this medication may cause dependence." "Stop taking this medication if your symptoms do not improve by tomorrow."

"Taking this medication may increase your risk of an abnormal heart rhythm." Rationale: Loperamide decreases GI motility and is a nonprescription drug. It does not cause the central nervous system effects associated with opiate derivatives and lacks the potential for abuse. Loperamide should not be continued after 48 hours if improvement has not occurred. Loperamide has a black box warning because torsades de pointes, cardiac arrest, and death have been reported in people using higher than recommended dosages. Alcohol can increase the nervous system side effects of loperamide, such as dizziness, drowsiness, and difficulty concentrating.

The nurse is educating a client about the use of fentanyl citrate via a patient-controlled analgesia pump. Which of the following statements should be included in the teaching? "You cannot breastfeed your baby while using a patient controlled analgesia pump." "You may get drowsy if you press the administration button too many times." "The administration button should not be pressed by anyone other than you." "A patient controlled analgesia pump reduces the risk of post-partum hemorrhage."

"The administration button should not be pressed by anyone other than you." Rationale: A patient-controlled analgesia (PCA) pump is a device that the client can use to self-administer medication. The client is the only person who should press the administration button. These devices have a "lockout" that prevents the client from administering too many doses. The PCA pump does not affect the likelihood of hemorrhage, and clients may breastfeed while using the device.

The nurse is providing education to the client receiving total parenteral nutrition (TPN) in the home setting. Which of the following statements by the client indicates the need for further teaching? "The bags can be stored on the kitchen counter." "I need to contact my provider if I feel numbness or weakness." "I should weigh myself at the same time daily." "There should be no redness around the catheter insertion site."

"The bags can be stored on the kitchen counter." Rationale: Nurses are involved in educating the client about the techniques and responsibilities associated with TPN and providing technical and psychological support to the client receiving TPN in the home. Client education should specifically include proper storage of parenteral nutrition containers and supplies, infection prevention measures, signs and symptoms of glucose alterations, signs and symptoms of abnormal electrolytes and fluid volume excess, signs of infection, and basic care of the venous access device.

The nurse is educating a client receiving chemotherapy about newly prescribed ondansetron regular tablets. What statement by the nurse is appropriate? "The medication works best if taken before you are nauseous." "Take the medication with only a sip of water." "This medication could cause difficulty with sleep." "You may experience constipation with this medication."

"The medication works best if taken before you are nauseous." Rationale: Ondansetron is a serotonin 5-HT3 receptor antagonist. It works by blocking the action of serotonin to treat nausea and vomiting. When taking ondansetron for nausea that occurs with meals, then the standard tablet should be taken half an hour to 1 hour before meals. Headache and diarrhea are common side effects. It can also cause dizziness and impaired gait and balance. Ondansetron may mask an ileus and gastric distention.

The nurse is educating a client about the use of nitrous oxide in labor. Which of the following statements should the nurse include in the teaching? "Using nitrous oxide may cause the baby to have lower APGAR scores." "Nitrous oxide is administered through your IV catheter." "If you use nitrous oxide, you cannot get an epidural afterward." "The most common side effects of nitrous oxide are nausea and dizziness."

"The most common side effects of nitrous oxide are nausea and dizziness." Rationale: Nitrous oxide is an inhaled medication that has a rapid onset and clearance. Because its half-life is so short, other methods of pain control, such as an epidural, can be used almost immediately after discontinuing the medication. Nitrous oxide does not affect APGAR scores, and the most common side effects are nausea, vomiting, and dizziness.

A nurse is giving instructions to the parents of a newborn infant with oral candidiasis. Which statement made by a parent is incorrect and indicates a need for more teaching? A "Nystatin should be given four times a day after my baby eats." B "I will use a dropper to place the medicine on each side of my baby's mouth." C "I will boil the nipples and pacifiers for 20 minutes." D "The therapy can be discontinued when the spots disappear."

"The therapy can be discontinued when the spots disappear." Rationale: The therapy should be continued for a week, even if lesions have disappeared within a few days. If the mother is breast-feeding, mother and baby should be treated at the same time to prevent re-infection.

The nurse is providing care for a client after surgery. The client has an order for acetaminophen with codeine. The client asks the nurse what to expect after taking this medication. Which is the best response by the nurse? A "This medication combination will allow healing to occur faster." B "This medication will minimize any side effects from the codeine." C "The combination medication will reduce the chance of addiction." D "This combination medication will better help to manage your pain."

"This combination medication will better help to manage your pain." Rationale: A post-operative client experiencing pain may receive opioid or non-opioid pain medication, in addition to non-pharmacologic comfort measures. The use of acetaminophen with codeine potentiates the effect of the codeine, thus providing greater/better pain relief. The presence of codeine doesn't alter the chance of addiction or reduce the chances of side effects. The medication will not affect healing.

The nurse is talking with a client who was admitted with an acute myocardial infarction due to coronary artery disease. The clients asks what the purpose for the prescribed carvedilol is. How should the nurse respond? A "A beta blocker will prevent postural hypotension." B "Most people develop hypertension after a heart attack." C "Beta blockers will help to increase your heart rate." D "This drug will decrease the workload on your heart."

"This drug will decrease the workload on your heart." Rationale: One action of beta blockers is to decrease systemic vascular resistance by dilation of the arterioles. This is useful for clients with coronary artery disease and will reduce the risk of another MI or a sudden cardiac event. Some of the more commonly prescribed beta blockers include metoprolol and carvedilol (Coreg). The other responses are incorrect.

The nurse is educating a client with end-stage renal failure about newly prescribed aluminum hydroxide. Which statement should the nurse include in the teaching? "This medication binds with phosphates from food to decrease absorption." "This medication is used to decrease urea to prevent urticaria." "This medication will coat the lining of the stomach to decrease acid production." "This medication treats hyperkalemia by exchanging sodium for potassium in the intestines."

"This medication binds with phosphates from food to decrease absorption." Rationale: Hyperphosphatemia occurs in end-stage renal failure when kidneys can no longer filter out phosphorus. Treatment of hyperphosphatemia may include the administration of aluminum hydroxide as a phosphate-binding agent. The aluminum binds with phosphates which are excreted in the feces. Sodium polystyrene is used to treat hyperkalemia by exchanging sodium for potassium in the intestines. Dialysis is used to remove urea from the blood, and diphenhydramine is used to treat urticaria. Sucralfate is a medication that coats the stomach lining to decrease acid production.

The nurse is teaching a pediatric client and family about prescribed albuterol sulfate extended-release tablets. Which statement should be included? "If you cannot swallow the tablet, it is ok to chew it." "This medication can cause restlessness." "Rinse your mouth after taking this medication." "Oral albuterol can cause an increase in urination."

"This medication can cause restlessness." Rationale: The adverse reactions to albuterol are the same whether administered orally or via inhalation. The most frequent adverse reactions to albuterol are nervousness, tremors, headache, tachycardia, and palpitations. Less frequent adverse reactions are muscle cramps, insomnia, nausea, weakness, dizziness, drowsiness, flushing, restlessness, irritability, chest discomfort, and difficulty in urination. Extended-release medications should not be chewed or crushed. Doing so can release all of the drug at once, increasing the risk of side effects. Inhaled corticosteroids require the mouth to be rinsed. This medication is not inhaled and is not a corticosteroid.

The nurse educating a client who is postpartum about the use of ibuprofen for uterine cramping. Which statement should the nurse include in the teaching? "This medication could cause gastrointestinal discomfort." "You may experience decreased vaginal discharge with this medication." "Taking this medication could decrease your breast milk production." "You could experience dizziness while taking this medication."

"This medication could cause gastrointestinal discomfort." Rationale: Ibuprofen, which is an NSAID, can cause gastrointestinal upset, especially if taken frequently without food. Ibuprofen can increase the risk for bleeding, so the client should monitor vaginal discharge. Ibuprofen does not affect breast milk production. Medications that cause vasodilation, such as beta-blockers, could cause dizziness.

The clinic nurse is collecting data from a client who is taking prescribed methylphenidate for the treatment of attention deficit hyperactivity disorder (ADHD) and is requesting an increase in the dose. Which statement by the client would require immediate follow-up by the nurse? "I think I have lost weight since I started taking the medication." "This medication is not calming me down even with green tea." "I take more naps during the day on this medication." "I am performing better at work but need to be more engaged."

"This medication is not calming me down even with green tea." Rationale: The use of caffeine-containing beverages (green tea) should be avoided with methylphenidate as it may potentiate the common side effects of this medication, including nervousness, restlessness, and palpitations. This statement would require follow-up by the nurse first. Anorexia (loss of appetite) and insomnia are other common side effects of this medication and should be discussed after addressing the misconception of the use of green tea. Methylphenidate acts to stimulate the central nervous system to increase focus, but it will not increase social interaction.

The nurse is teaching a client who has been diagnosed with recurrent genital herpes about newly prescribed valacyclovir. Which statement by the client indicates understanding? "This medication is preferable because I can take it less often than other antivirals." "I will be free of outbreaks from now on." "This medication will prevent transmission of the virus to my partner." "Starting the medication now will not help speed up healing."

"This medication is preferable because I can take it less often than other antivirals." Rationale: Valacyclovir has greater bioavailability than acyclovir does and is administered less frequently. It speeds up the healing process for lesions and reduces discomfort from the lesions, even if they've already developed. While antivirals do reduce the risk of transmitting herpes simplex to partners, it is not eliminated. The number of outbreaks may be reduced but also may not be completed eliminated.

The nurse is educating a client with preeclampsia about magnesium sulfate. Which statement should the nurse include in the teaching? "This medication is used to reduce your risk of seizures." "This medication will raise your blood pressure." "This medication might make you urinate more frequently." "This medication will be discontinued once your headache subsides."

"This medication is used to reduce your risk of seizures." Rationale: Magnesium sulfate is a medication that is used to prevent seizures for clients with preeclampsia. The medication will not raise blood pressure and has no effect on urination. Magnesium is given continuously and will not be discontinued if the client's headache subsides.

The nurse is educating a client on the use of nalbuphine for labor pain management. Which of the following statements should be included in the teaching? "This medication may cause you to be drowsy." "This medication will reduce the strength of your contractions." "This medication can be given all the way up until delivery." "This medication may cause maternal hypertension."

"This medication may cause you to be drowsy." Rationale: Nalbuphine can cause sedation, drowsiness, nausea, and vomiting. The medication does not affect the strength of contractions or cause maternal hypertension. Nalbuphine should not be given immediately before delivery, as it increases the risk for respiratory distress.

The nurse is preparing to administer oxytocin to a client for induction of labor. Which of the following statements by the nurse is appropriate to include in client education? "This medication can cause you to feel sleepy." "This medication will be discontinued once your cervix starts to dilate." "This medication will be increased until you have an adequate contraction pattern." "This medication can make you feel dizzy."

"This medication will be increased until you have an adequate contraction pattern." Rationale: Oxytocin is used to increase the frequency, duration, and strength of contractions and will be increased until the client's contractions are 2-3 minutes apart. The medication will not cause the client to feel sleepy and they can get out of bed dependent on the client's condition. Oxytocin will not be discontinued until delivery unless the maternal or fetal condition is unstable.

The nurse is providing medication teaching for a client prescribed famotidine for the treatment of gastroesophageal reflux disease (GERD). Which statement by the client indicates an understanding of the teaching? "I will take this medication once a day in the morning." "I will no longer have discomfort at night once I begin this medication." "This medication will both prevent and treat heartburn." "My treatment will be done in one week."

"This medication will both prevent and treat heartburn." Rationale: H2 receptor blockers (antagonists) are used to prevent and treat conditions caused by too much acid being produced in the stomach. These conditions include gastric ulcers, duodenal ulcers, and GERD. Famotidine may be prescribed to take twice a day, in the morning and evening, or just once daily in the evening. Duration of treatment varies but is at a minimum two weeks.

The nurse is educating a client on the use of misoprostol for induction of labor. Which of the following statements should the nurse include in the teaching? "This medication will soften your cervix." "This medication increases the risk of bleeding." "This medication is used to help reduce the pain of contractions." "This medication can cause nausea."

"This medication will soften your cervix." Rationale: Misoprostol is a medication that is used to soften the cervix and increase contractions. It can be administered vaginally or orally for induction of labor. This medication does not increase the risk of bleeding or reduce pain. Nausea is not a side effect of misoprostol.

A nurse is educating a client with diabetes type 2 about newly prescribed glipizide. Which statement by the nurse best describes the action of glipizide? "This medication absorbs the excess carbohydrates from your intestinal tract." "This medication will inhibit the release of glucose stored in the liver." "This medication will stimulate your pancreas to release insulin." "This medication works by increasing the ability of the cells to uptake glucose."

"This medication will stimulate your pancreas to release insulin." Rationale: The action of sulfonylureas, such as glyburide, is to stimulate the pancreas to release insulin. Biguanides, such as metformin, work by decreasing the release of glucose from the liver and increasing the uptake of glucose into the cells. The action of a-glucosidase inhibitors is to decrease the absorption of carbohydrates in the gastrointestinal tract.

The nurse is providing education to the parent of a pediatric client receiving amoxicillin clavulanate suspension. Which of the following statements is appropriate? "Use the measuring device provided by the pharmacy." "You should take this medication on an empty stomach." "Avoid shaking the medication before opening." "Take the medication with a glass of juice."

"Use the measuring device provided by the pharmacy." Rationale: Take augmentin (amoxicillin clavulanate) with meals to increase absorption and decrease GI upset. Acidic fluids may destroy the drug, so avoid taking the medication with citrus juice. The client should be taught to shake liquid penicillins well as the medication tends to separate out of the suspension. Measure liquid doses carefully. Use the measuring device that comes with this drug. If there is none, ask the pharmacist for a device to measure this drug.

The nurse is providing education to the client with sinusitis who has asked about taking over-the-counter pseudoephedrine. Which of the following statements is appropriate? "If you take pseudoephedrine and phenylephrine together, you will get more relief." "Continue the medication until your congestion resolves." "Using these kinds of medications may make you jittery and restless." "It is safe to chew over the counter medications if you have trouble swallowing pills."

"Using these kinds of medications may make you jittery and restless." Rationale: Do not combine two drug preparations containing the same or similar active ingredients. For example, pseudoephedrine is the nasal decongestant component of most prescription and over-the-counter (OTC) sinus and multi-ingredient cold remedies. Taking more than one preparation containing pseudoephedrine (or phenylephrine, a similar drug) may increase the dosage to toxic levels and cause irregular heartbeats and extreme nervousness. Oral OTC decongestants should not be used longer than one week. Excessive or prolonged use may damage nasal mucosa and produce chronic nasal congestion. Common side effects include tachycardia, impaired coordination, dizziness, excitability, headache, insomnia, restlessness, seizures, vertigo, dysuria, urinary retention, urinary difficulty, and thrombocytopenia.

The nurse in a pediatrician's office is speaking with the parent of an 8-year-old child who is concerned about the child receiving the annual flu vaccine due to an egg allergy. How should the nurse respond? A "We can premedicate the child to prevent an allergic reaction." B "Your child should not be receiving the flu vaccine." C "We have new types of flu vaccines where an egg allergy does not matter." D "You can schedule an appointment to have the vaccine administered in our office."

"You can schedule an appointment to have the vaccine administered in our office." Rationale: The Centers for Disease Control and Prevention (CDC) states that people with egg allergies can receive any licensed, recommended age-appropriate influenza (flu) vaccine (IIV, RIV4, or LAIV4) that is otherwise appropriate. People who have a history of severe egg allergy (those who have had any symptom other than hives after exposure to egg) should be vaccinated in a medical setting, supervised by a health care provider who is able to recognize and manage severe allergic reactions. The other responses are not correct.

The nurse is teaching a client who is postoperative cesarean section about newly prescribed oxycodone. Which statement should the nurse include in the client teaching about this medication? "You may experience some constipation while taking this medication." "Mothers who take this medication often have trouble with breastfeeding." "This medication may cause difficulty with sleeping." "Your vaginal bleeding may increase while taking this medication."

"You may experience some constipation while taking this medication." Rationale: Opioids, such as oxycodone, are used to treat postoperative pain. Opioids can slow down the gastrointestinal system, which may result in constipation. Opioids do not affect the ability to breastfeed. Opioids can cause increased drowsiness. Opioids do not increase vaginal bleeding.

A preop nurse is initiating peripheral intravenous access on a client scheduled for surgery. The nurse selects an 18-gauge catheter for insertion. The client asks the nurse why the catheter needs to be so large. How will the nurse respond to the client's concern? "You may require rapid fluid infusions during the surgery." "I can use a smaller gauge if that makes you feel comfortable." "You have large veins that can accommodate this catheter." "Tell me why you are concerned about the size of the catheter."

"You may require rapid fluid infusions during the surgery." Rationale: A larger gauge catheter (18 to 20) should be initiated on clients scheduled for surgery. Unexpected events during surgery may require rapid fluid infusions or blood administration. The nurse should educate the client on the need for a large gauge. A smaller gauge should be avoided unless initiating access on the client is difficult. Vein size is not the reason that a large gauge is required. Surgery requires larger gauge catheters for rapid fluid infusions. Asking the client to express their concerns is part of therapeutic communication but does not address the concerns.

The nurse is teaching the client with bacterial vaginosis who has been prescribed metronidazole tablets. What statement is appropriate? "You may continue to experience symptoms after you stop the medication." "You should avoid drinking alcohol while taking this medication." "Call your healthcare provider if you experience diarrhea." "Your sexual partner will need to be treated as well."

"You should avoid drinking alcohol while taking this medication." Rationale: Alcohol should be avoided while on metronidazole to reduce the risk of a disulfiram reaction. Routine treatment of male sexual partners is not needed and does not affect re-infection rates. If the client experiences continued symptoms, this may indicate treatment failure and the need for follow-up may be required. Diarrhea is a common side effect of metronidazole and should subside once treatment ends.

The nurse is educating a pregnant client about newly prescribed betamethasone. Which of the following statements should the nurse include in the teaching? "Betamethasone reduces your risk of preterm labor if administered correctly." "You will need to return to the clinic tomorrow for your second dose of betamethasone." "Betamethasone may cause significant maternal weight gain." "Take betamethasone every four hours unless you begin having contractions."

"You will need to return to the clinic tomorrow for your second dose of betamethasone." Rationale: Betamethasone steroid is administered to hasten fetal lung maturity. It is given in two doses, 24 hours apart, as an intramuscular injection. Betamethasone does not affect contraction pattern, maternal weight, or reduce the likelihood of preterm labor.

The nurse is preparing to administer penicillin to a laboring client who is group beta strep positive. Which of the following statements by the nurse should be included in the client education? "This medication will prevent outbreaks after delivery." "You will receive additional doses of the medication until delivery." "This medication may cause facial flushing." "Your contractions will become more frequent while taking this medication."

"You will receive additional doses of the medication until delivery." Rationale: IV penicillin is used to treat group beta strep (GBS) positive mothers while the client is in labor and additional doses will be administered until delivery. GBS is not a sexually transmitted infection and does not affect contraction pattern. Facial flushing is not a side effect of this medication.

The nurse has administered a dose of betamethasone to a client who is 34 weeks gestation. Which statement should the nurse make when discussing the side effects of the medication with the client? "This medication will treat your hypertension." "Your blood glucose level could increase with this medication." "Taking this medication will prevent pre-term labor." "You may experience increased urination while taking this medication."

"Your blood glucose level could increase with this medication." Rationale: Betamethasone is a glucocorticoid that often causes an increase in maternal blood glucose. The nurse should monitor blood glucose closely after administration in clients with diabetes. Beta-blockers, such as metoprolol, decrease blood pressure. Terbutaline is a medication used to treat pre-term labor. Diuretics, such as furosemide, will increase urine output.

A nurse is administering insulin glargine to a client with diabetes type I. The client asks the nurse why insulin is the only option for therapy. Which statement by the nurse is appropriate? "Your body does not produce an adequate amount of insulin." "Insulin is better at controlling the disease than oral pills." "Your body has a resistance to insulin." "Oral pills take longer to produce therapeutic effects than insulin."

"Your body does not produce an adequate amount of insulin." Rationale: Diabetes mellitus type 1 is characterized by the inability of the beta cells to produce insulin. The disease is managed by implementing an insulin regimen. Oral hypoglycemic medications are not effective in treating diabetes type 1. The body's resistance to insulin is characteristic of diabetes mellitus type 2. The onset of oral hypoglycemic medications is not relevant to a client with diabetes mellitus type 1.

A nurse receives a prescription to administer 200 mcg of hydromorphone to a client. The hydromorphone is supplied in a 1 mg/ml vial. How many milliliters will the nurse administer to the client? 0.5 2 0.2 2.5

0.2 Rationale: The nurse will administer 0.2 milliliters (ml) of hydromorphone. The vial contains 1 milligram (mg) of medication for every 1 ml. 1 mg = 1,000 micrograms (mcg). The prescription is for 200 mcg. (200 / 1,000 = 0.2 mg). The total volume needed is 0.2 ml. The other volumes are not consistent with the dosage calculations.

A nurse receives a prescription to administer 0.05 mg/kg of morphine IM to an infant who weighs 9 kg. How will the nurse document the administration of the medication? 0.2 mg administered IM into the ventrogluteal site 0.45 mg administered IM into the vastus lateralis 0.2 mg administered IM into the dorsogluteal site 0.45 mg administered IM into the deltoid muscle

0.45 mg administered IM into the vastus lateralis Rationale: The vastus lateralis is the preferred site for intramuscular injections in an infant. The thickness of the thigh muscle is better developed than in other areas during infancy. The correct dosage to administer is 0.45 mg (0.05 mg x 9 kg = 0.45 mg). The deltoid muscle is not well developed in infants and is not the preferred site for intramuscular injection administration. The ventrogluteal site is not the preferred area for IM administration in an infant. Additionally, 0.2 mg is not the correct dose of medication. The dorsogluteal site is not indicated for IM injections in an infant. There is an increased risk of nerve damage when using this site.

The nurse is caring for a post-surgical client who is using patient controlled analgesia (PCA) with morphine for pain management. The client reports that the pain is severe and does not get better, even after "pushing the PCA button". Indicate the sequence of actions the nurse should take in the correct order. 1 Verify that the client is using the PCA equipment correctly. 2 Check the MAR for adjuvant medications. 3 Confirm that the pump is working and the tubing is patent. 4 Offer non-pharmacological interventions. 5 Consult with the health care provider. 1, 3, 2, 4, 5 1, 2, 3, 4, 5 5, 4, 1, 2, 3 4, 5, 1, 2, 3

1, 3, 2, 4, 5 Rationale: The nurse should implement the interventions/actions in the following order: (1) Verify that the client understands how to use the PCA equipment correctly, (2) assess if the PCA pump is functioning properly and medication is being delivered, (3) determine if the client is able to receive additional or adjuvant medication for pain management, (4) offer non-pharmacological interventions such as repositioning, diversional activities and rest. Lastly, (5) the nurse should notify the health care provider if the client's pain level does not improve.

The nurse is preparing to administer to a client an IV heparin to infuse at 20 ml/hr. The heparin bag reads 25,000 units/250 ml. How many units per hour should the client receive?

2000 Rationale: units/hr = (25,000 units / 250 ml) x (20 ml/hr) = 500,000 / 250 = 2,000

The nurse is preparing to administer an intramuscular injection to an adult client using the deltoid site. Which of the following needle sizes would be an appropriate choice for this injection? 18 gauge, 5/8 inch needle 30 gauge, 2 inch needle 25 gauge, 1 inch needle 16 gauge, 1.5 inch needle

25 gauge, 1 inch needle Rationale: An intramuscular injection requires a needle that is long enough to reach the muscle tissue at the deltoid site; this is typically 5/8 inches to 1.5 inches. The gauge of the needle should be 20-25 gauge.

The nurse is caring for a client who has a prescription for an insulin sliding scale to manage the client's hyperglycemia. At 11 am, the client's blood glucose level was 285 mg/dL. According to the following sliding scale parameters, how many units of insulin should the nurse administer? (For glucose less than 140, give 0 units of insulin aspart. For glucose between 140 to 180, give 2 units of insulin aspart. For glucose between 181 to 220, give 4 units of insulin aspart. For glucose between 221 to 260, give 6 units of insulin aspart. For glucose between 261 to 300, give 8 units of insulin aspart. For glucose greater than 300, notify the health care provider.) 2 units 4 units 6 units 8 units

8 units Rationale: According to the prescribed sliding scale, for a blood glucose level of 285 mg/dL, the nurse should administer 8 units of insulin aspart.

The nurse on a surgery unit is evaluating which client would be appropriate for patient-controlled analgesia (PCA). Which client would not be appropriate for PCA? A A 71-year-old client with numerous arthritic nodules on their hands. B A 16-year-old client who reads at a fourth-grade level. C A 25-year-old client with a history of Down syndrome. D A 4-year-old client with intermittent episodes of alertness.

A 4-year-old client with intermittent episodes of alertness. Rationale: The 4-year-old client (preschool-aged) is most likely to have difficulty with the use or understanding of a patient-controlled analgesia (PCA) pump. The preschooler also has a decreased level of consciousness and would not be able to fully benefit from the use of a PCA pump. School age children, ages 6 and up, are better candidates for PCA electronic pumps.

A nurse is performing pain assessments on several clients. Which client would benefit the most from the administration of intravenous PRN pain medication? A client eating breakfast verbalizing a headache A client with a fractured arm pending discharge A client post-abdominal surgery sitting in a chair A client pending bedside debridement of a wound

A client pending bedside debridement of a wound Rationale: Intravenous pain medication has a rapid onset. A bedside wound debridement is a complex, painful procedure. This client would benefit the most from IV pain medication. A client with a headache who is able to tolerate meals and a postoperative client who is able to reposition may benefit from pain medication via a different route (oral). A client pending discharge should no longer require intravenous pain medication. Discharge criteria include pain management with less invasive options.

To which nursing home resident could a nurse safely administer tricyclic antidepressants (TCAs) without questioning the health care provider's order? A A client with coronary artery disease (CAD) B A client with benign prostatic hypertrophy (BPH) C A client with narrow-angle glaucoma D A client with mild hypertension

A client with mild hypertension Rationale: Tricyclics can be safely administered to the hypertensive client. The expected anticholinergic effects of tricyclic antidepressants include difficulty in urination, which is why TCAs are contraindicated with BPH. TCAs are also contraindicated in narrow-angle glaucoma (they can cause elevated pressure in the eyes) and for certain heart abnormalities.

The infection control nurse is evaluating the infection prevention procedures on the unit. Which of the following observed by the nurse would require intervention? The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing. A nurse with open, weeping lesions on the hands puts on gloves before giving direct client care. Staff are not wearing gloves when feeding clients in the common dining area.

A nurse with open, weeping lesions on the hands puts on gloves before giving direct client care. Rationale: Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves; this helps prevent the spread of any pathogens. There is no need to wear gloves when feeding a client. However, universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations. A client with active tuberculosis should be on respiratory precautions. Having the client wear a mask when leaving his private room is appropriate to prevent exposure to others. Strict isolation requires the use of a mask, a gown, and gloves.

The nurse is documenting an occurrence in which a client fell during a transfer and resulted in an intracerebral hemorrhage and death. Which type of practice error should the nurse document as having occurred? A sentinel event A near-miss event A never-event An unpreventable event

A sentinel event Rationale: The nurse should document the death of a client following a fall during a transfer on the unit as a sentinel event. A sentinel event is one in which serious injury or death occurred due to errors. Never-events are defined by the Joint Commission as surgeries on the wrong body part, foreign objects placed in the client after surgery, or mismatched blood transfusions. A near-miss event is the identification of any event or situation that might have resulted in client harm, but the harm did not occur due to timely intervention by healthcare staff. An unpreventable event is one in which death or client injury would occur in the absence of a medical error.

A nurse is preparing to administer plasma to a client with a coagulation disorder. Which identification step will the nurse verify prior to initiating the transfusion? Cross match Expiration date ABO compatibility Hemoglobin level

ABO compatibility Rationale: Plasma is a blood product that needs to be typed prior to administration to avoid a reaction. Typing determines if the blood product is compatible with the client's blood type. A cross match for antigens is only required for transfusions containing red blood cells. The expiration date is an important component to check prior to administration. However, this does not identify the client. Plasma does not contain red blood cells, so checking the hemoglobin level is not indicated and does not identify the client.

A nurse is reviewing laboratory data prior to administering methotrexate to a client with breast cancer. Which clinical finding will the nurse report to the healthcare provider before administering the medication? ALT of 55 IU/mL WBC of 12,000/mm³ AST of 34 U/L HGB of 11.5 g/dL

ALT of 55 IU/mL Rationale: Alanine transaminase (ALT) is a liver enzyme that is released into the bloodstream when liver damage is present. Methotrexate is an antineoplastic used in the treatment of various carcinomas. Methotrexate is contraindicated in clients with hepatic impairment. A higher than normal white blood cell (WBC) count is an expected finding in a client with carcinoma. Aspartate aminotransferase (AST) is a liver enzyme used to assess hepatic function. An AST level of 34 U/L is a normal finding. Anemia (low hemoglobin) is an expected finding in a client with carcinoma.

A nurse is evaluating a client who was prescribed 30 mg of codeine after oral surgery. Which assessment finding indicates the expected outcome of the medication? Normoactive bowel sounds Absence of pain Decreased cough reflex Normal respiratory rate

Absence of pain Rationale: Codeine is an opioid analgesic used primarily in the treatment of mild to moderate pain. The expected outcome of codeine taken after oral surgery is the absence of pain. Codeine may cause constipation and respiratory depression. Normoactive bowel sounds and a normal respiratory rate indicate the absence of side effects of codeine but do not suggest an expected outcome. A decreased cough reflex is expected when codeine is used in smaller doses (10-20 mg) as an antitussive.

A nurse is assessing a client with heart failure who is taking prescribed torsemide. Which clinical finding indicates effectiveness of the medication? Symmetrical pulses bilaterally Full strength to bilateral extremities Intact whisper test Absence of peripheral edema

Absence of peripheral edema Rationale: Torsemide is a loop diuretic used in the treatment of hypertension and fluid overload. The expected therapeutic response of torsemide is a decrease in fluid retention evidenced by the absence of peripheral edema. Symmetrical pulses bilaterally and full strength to bilateral extremities do not evaluate the effectiveness of torsemide. An intact whisper test indicates the absence of ototoxicity, an adverse effect of torsemide. However, this does not evaluate medication effectiveness.

A healthcare provider is prescribing an analgesic to a client who is pregnant. Which medication does the nurse expect to administer and record in the client's medication administration record? Naproxen Diclofenac Acetaminophen Ibuprofen

Acetaminophen Rationale: Acetaminophen is safe for use in clients who are pregnant. Acetaminophen is a Pregnancy Risk Category B. Naproxen, diclofenac, and ibuprofen are first-generation non-steroidal anti-inflammatory medications with a Pregnancy Risk Category D, which are contraindicated for a client who is pregnant.

The nurse is reviewing the plan of care for a group of assigned clients. For which client should the nurse anticipate a prescription for total parenteral nutrition (TPN)? Bladder cancer ST elevation myocardial infarction Acute pancreatitis Diabetes type 2

Acute pancreatitis Rationale: Clients with pancreatitis need to be NPO to prevent stimulation of the pancreas. Total parenteral nutrition (TPN) is a nutrient solution consisting of dextrose, amino acids, lipids, and select electrolytes, vitamins, minerals, and trace elements that must be infused through a central vein because of its hypertonicity. TPN is frequently given to clients with severe inflammatory bowel disease, severe pancreatitis, or acquired immunodeficiency syndrome (AIDS), who are unable to meet their nutritional needs through the oral or enteral routes. Enteral nutrition is still considered optimal.

The nurse is preparing to administer 0600 medications to a client. The client is prescribed levothyroxine 125 mcg PO daily for hypothyroidism. The medication package states levothyroxine tablet 0.125 mg. Which action is appropriate? Administer the medication Call the pharmacy and ask them to deliver the correct dose Hold the medication until the healthcare provider arrives Call the healthcare provider and request that the time of administration be changed

Administer the medication Rationale: Levothyroxine is taken in the morning on an empty stomach. Administering the medication later in the day reduces the efficacy. A typical dose of levothyroxine ranges from 100-200 mcg/day. Often the medication packages display the dose in milligrams, so the dose must be converted. In this case, it is safe to administer the medication as provided. It is important to check the dosage as part of the checks/rights of medication administration (right medication, right patient, right dosage, right route, and right time).

The client is diagnosed with tuberculosis (TB). The nurse understands that the treatment plan for this client will involve what type of drug therapy? A High doses of B complex vitamins B An anti-inflammatory agent C Aminoglycoside antibiotics D Administering two antituberculosis drugs

Administering two antituberculosis drugs Rationale: In order to prevent drug-resistant strains of TB, clients are always prescribed at least two different anti-tubercular medications. Rifampin and isoniazid are the most effective drugs used to treat TB and are always used together, for at least six months. Additional medications, such as pyrazinamide and either streptomycin or ethambutol, may also be prescribed. Vitamin B6 is usually prescribed to help prevent expected side effect of isoniazid.

The client has been prescribed sertraline for depression. Which action should the nurse include in the plan of care? Advise that the medication will be tapered prior to discontinuation Monitor for signs of physical addiction Emphasize that relief of symptoms occurs in one week Assess for symptoms of a thrombus formation

Advise that the medication will be tapered prior to discontinuation Rationale: Sertraline, a selective serotonin reuptake inhibitor (SSRI), should be tapered with provider supervision prior to discontinuation. Abrupt discontinuation can result in withdrawal symptoms including nausea, sweating, agitation, tremors, insomnia, and seizures. Sertraline does not cause physical addiction. Therapeutic actions include enhancement of mood after several weeks. Increased incidence of clotting disorders is not associated with sertraline and may have a blood-thinning effect.

The nurse working in pediatrics is admitting a client with a diagnosis of measles. Which of the following transmission-based precautions should be instituted? Airborne Contact Droplet Reverse

Airborne Rationale: The client with measles should be placed on airborne precautions. Patients with measles should remain in Airborne Precautions for 4 days after the onset of rash (with the onset of rash considered to be Day 0). Standard precautions should be adhered to, as is the case for all patients. Reverse isolation is designed for immunosuppressed clients.

The nurse is preparing to administer ceftriaxone to a client. Which of the following findings from the client's medical record should cause the nurse to question this prescription? White blood cells in the urine History of hypertension Allergy to cephalexin Current tobacco smoker

Allergy to cephalexin Rationale: Ceftriaxone and cephalexin are both cephalosporins; therefore, an allergy to cephalexin should cause the nurse to question any prescription for a cephalosporin. Hypertension and tobacco use do not affect the ability to take ceftriaxone. Elevated white blood counts (WBCs) in the urine indicate a possible infection and may be why antibiotics were prescribed, but this finding should not cause the nurse to be concerned about the medication.

The nurse is preparing to administer magnesium sulfate IV to a client with preeclampsia. Which medication in the client's record should the nurse question this prescription? Penicillin Betamethasone Lactated ringers Amlodipine

Amlodipine Rationale: Magnesium sulfate potentiates the action of calcium channel blockers so the nurse should be concerned about administering amlodipine and magnesium sulfate together. Betamethasone is a steroid that is commonly given to clients in preterm labor but does not interact with magnesium sulfate. Penicillin does not have any known interactions with magnesium sulfate, and lactated ringers is an IV fluid that magnesium sulfate is mixed into to administer intravenously.

A nurse is providing care to a trauma client requiring significant fluid resuscitation. The nurse will initiate venous access at which site? Forearm Scalp Subclavian Antecubital

Antecubital Rationale: The nurse should initiate peripheral venous access at the antecubital fossa site. The antecubital area contains large veins that can sustain large-bore IV catheters for rapid infusions. The forearm has smaller diameter veins and is not the site of choice for fluid resuscitation. Scalp veins are very small in diameter and are not indicated for rapid fluid infusion. The subclavian area requires a central line, which is a skill not within the nurse's scope of practice.

A nurse is observing a graduate nurse (GN) perform a dressing change on a client's femoral central line. Which action by the GN requires an intervention by the nurse? Puts on a mask prior to performing the dressing change Cleans the skin around the site with CHG solution Applies clean gloves after opening the dressing kit Uses an alcohol pad to remove the adhesive stabilization device

Applies clean gloves after opening the dressing kit Rationale: A central line dressing change is a sterile procedure. The graduate nurse (GN) should apply sterile gloves after opening the sterile dressing kit. A mask protects the central line access site from airborne microorganisms. Chlorhexidine gluconate is the preferred antiseptic solution for cleaning the skin around the central line access site. Using an alcohol pad to remove adhesive devices reduces the risk of skin injury.

The nurse is caring for a client receiving IV therapy. The nurse understands which of the following techniques is the best way to assess for infiltration? A Check for blood return B Perform a flush C Assess for erythema at the site D Apply a tourniquet above the transfusion site

Apply a tourniquet above the transfusion site Rationale: Infiltration is the unintentional administration of solution or medication into surrounding tissue. Checking for blood return could be a false indicator that the site is working properly. The more reliable way to check for infiltration is to apply a tourniquet above the infusion site. Assessing for erythema is not an indication of infiltration but could indicate several abnormal instances. which could include allergy to the adhesive used to secure the site. Performing a flush may indicate leaking.

The nurse is preparing to replace a client's prescribed transdermal patch. Which of the following actions should the nurse perform first? Place the patch on the client's skin Label the new patch with date and time Apply clean gloves Remove the old patch

Apply clean gloves Rationale: The nurse should apply gloves before handling any topical medication; this includes gloving prior to removing an old transdermal patch. The patch should be removed and then a new patch placed on an alternative location. After it has been placed, the nurse should label the patch with the date and time.

A very active 2-year-old child pulls out a tunneled central venous catheter. What initial nursing action is most appropriate? A Obtain emergency equipment. B Assess heart rate, rhythm and all pulses. C Use cold packs at the exit incision site. D Apply pressure to the vessel insertion site.

Apply pressure to the vessel insertion site. Rationale: If a central venous catheter is accidentally removed, pressure should be applied to the vein exit site and chest area above it with gauze dressing or a clean washcloth. The primary care provider should be notified. Cold packs are not indicated at this time. At this point, emergency equipment is not required. The assessments are all done routinely.

The home health nurse is completing a medication reconciliation of a client who has a new prescription for warfarin. Which medication should the nurse question the healthcare provider about? Aspirin Nifedipine NPH insulin Vitamin D supplement

Aspirin Rationale: Warfarin is an anticoagulant that prevents blood from clotting by blocking the synthesis of vitamin K. Clients taking warfarin are at increased risk for bleeding. Aspirin, which is an anti-platelet aggregation, prevents platelets from clumping together. Taking warfarin and aspirin together could increase the risk of bleeding and should be questioned. Nifedipine is a calcium channel blocker and does not interact with warfarin. Insulin and vitamin D supplement do not cause adverse effects when taken with warfarin.

The nurse is preparing to administer medications through a gastrostomy tube. The nurse should contact the health care provider before giving which drugs through the gastrostomy tube? Select all that apply. Aspirin EC Metoprolol XL Acetaminophen Terazosin IR Calcium carbonate Diltazem SR

Aspirin EC Metoprolol XL Diltazem SR Rationale: Sustained-release (SR), extended-release (ER), or long-acting (XL) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube (G-tube) administration, sustained-release properties and blood levels of the drug will be altered. Enteric-coated (EC) drugs should also not be crushed. "IR" stands for immediate release, and those medications can be crushed. Absent any quantifier such as "ER" or "IR" with the drug name, the nurse should assume that the medication can be crushed and given through a G-tube.

The nurse is caring for a client with diabetes type I who received a prescribed dose of regular insulin 30 minutes prior to the meal. The client reports nausea and vomiting. Which action should the nurse take? Administer another dose of regular insulin Encourage the client to eat a small amount of carbohydrates Assess blood glucose level Notify the healthcare provider

Assess blood glucose level Rationale: When a client who has been administered a regular insulin injection vomits, the nurse should monitor blood glucose and frequently assess for signs of hypoglycemia. After 30 minutes, most of the medication would have been absorbed. Any food ingested may be lost, and repeating the dose would further lower glucose levels. Giving intravenous insulin would also lower glucose levels, causing further hypoglycemia. Before the nurse notifies the healthcare provider, the nurse should assess the client's blood glucose level.

The nurse is caring for a client admitted for an acute mania episode of bipolar disorder. The client reports stopping the prescribed lithium. Which action should the nurse do first? Ask the client why the medication was stopped Determine the client's serum lithium level Administer a stat lithium dose Assess the client's physiological needs

Assess the client's physiological needs Rationale: Because the client is experiencing an acute mania episode, the priority action would be for the nurse to address the client's physiological needs. It is important for the nurse to assess why the client is non-compliant with the medication prescribed for his condition. However, the client would not be able to answer the question in an acute manic state. Obtaining a serum lithium level would help guide treatment but does not take priority over the client's physiological needs. Since lithium takes 2-8 weeks to become therapeutic, a stat dose would not be effective.

The nurse is preparing to administer a client's oral medications. Which action should the nurse take prior to administration? Assess the client's swallowing ability Place the client in the supine position Remove any oxygen delivery devices Place all tablets into a pill cup together

Assess the client's swallowing ability Rationale: Prior to administration, the client's swallowing ability should be assessed. If any difficulty swallowing is identified, oral medications should not be administered. When administering oral medications, the client should be placed in a high-Fowler's position, and oxygen delivery devices should only be removed temporarily if they impede the ability to take the medication (a nasal cannula should not be removed). Oral medications should be administered one at a time rather than all together.

A nurse is providing care to a client who takes phenytoin for seizure prevention. The latest laboratory report shows a phenytoin level of 32 mcg/mL. Which action does the nurse take next? Examine the oral cavity Percuss the abdomen Check the skin turgor Assess the pupillary response

Assess the pupillary response Rationale: A phenytoin level of 32 mcg/mL is not an expected response to therapy. The therapeutic range of phenytoin is 10 to 20 mcg/mL. Signs of phenytoin toxicity include nystagmus, ataxia, and confusion. The pupillary response will assess for symmetrical movements of the eye. Examining the oral cavity, percussing the abdomen, and checking for skin turgor do not evaluate symptoms of phenytoin toxicity.

A nurse is assisting a client out of bed. As the client begins to stand, the bed moves back, and the client falls to the ground. The nurse notes the brakes on the bed were not activated. Which priority action does the nurse perform? Informs the charge nurse Assists the client back to bed Locks the brakes on the bed Assesses the client for injury

Assesses the client for injury Rationale: Assisted falls to the ground can still result in client injury. The nurse should assess the client for injuries prior to performing other interventions. Informing the charge nurse is an important action for the coordination of care. However, ensuring client safety is the priority. Assisting the client back to bed should occur after the nurse ensures there are no injuries from the fall. Locking the brakes on the bed will prevent a future fall. However, this action is not the priority.

The client is admitted for evaluation of lithium toxicity. Which of the following observations by the nurse would indicate that the condition is worsening? Dry mouth Drowsiness Increased thirst Ataxia

Ataxia Rationale: Ataxia, or loss of control of body movements, is a worsening sign of lithium toxicity. Common side effects of lithium therapy include drowsiness, dry mouth, and increased thirst.

A 76 year-old client is prescribed an anticholinergic metered dose inhaler (MDI) for chronic obstructive pulmonary disease (COPD). Why would the nurse suggest the client use a spacer? To help control the intake of the medication To increase client compliance to take the medication To enhance the administration of the medication To prevent further exacerbation of COPD

To help control the intake of the medication Rationale: An anticholinergic is used for maintenance therapy of airway obstruction due to chronic obstructive pulmonary disorder (COPD) including bronchitis and emphysema. The therapeutic effects are to cause bronchodilation and improve efforts of breathing. To improve the administration of the medication the nurse should suggest the client to use a spacer. This will help control the intake of the medication and reduce the amount of the medication that remains on the throat or tongue.

A nurse is preparing to administer insulin to a client with diabetes mellitus type 1. The client has regular insulin and insulin glargine prescribed. How will the nurse prepare these medications? Draw up the glargine insulin before the regular insulin Mix the insulins in a larger syringe Use a separate syringe for each insulin Draw up the regular insulin before the glargine insulin

Use a separate syringe for each insulin Rationale: Insulin glargine is a clear, long-acting insulin that should not be mixed with other insulins. Mixing insulin glargine with other medications can cause precipitate formation. The insulins should be drawn up in separate syringes. Short-acting insulins should be drawn up before long-acting insulins. However, insulin glargine should not be combined with any other medication. A larger syringe does not address incompatibility issues.

A 32-year-old female with human epidermal growth factor receptor 2-positive (HER2-positive) metastatic breast cancer is scheduled to begin therapy with pertuzumab. What information is important for the nurse to reinforce and discuss with the client? Select all that apply. Use contraception during and for 6 months following the use of this drug. Take the medication at the same time every day on an empty stomach. Other therapies for cancer treatment are no longer needed. Report shortness of breath, lightheadedness, dizziness, cough or swelling of the feet. Report chills, fatigue, or headache during treatment

Use contraception during and for 6 months following the use of this drug. Report shortness of breath, lightheadedness, dizziness, cough or swelling of the feet. Report chills, fatigue, or headache during treatment Rationale: Pertuzumab (Perjeta) is used in combination with trastuzumab (Herceptin) as a targeted therapy for HER2+ metastatic breast cancer; these medications are used in combination with chemotherapy and radiation. The most common side effects are fatigue, loss of taste, muscle pain and vomiting; sometimes slowing the infusion rate can help. It is best to eat a small meal before receiving the infusion. Serious side effects include birth defects and fetal death; women of child-bearing age must use a form of effective contraception during and for 6 months following treatment. Drugs that block HER2+ activity decrease left ventricular ejection fraction (LVEF) and will worsen symptoms of congestive heart failure; heart function must be tested before and monitored during treatment.

The nurse is caring for a client who has been prescribed vancomycin intravenous infusion for the treatment of methicillin-resistant staphylococcus aureus. Which of the following laboratory values should be immediately reported to the healthcare provider? Vancomycin trough of 15 mcg/dl Blood urea nitrogen level of 18 mg/dl Creatinine level of 1.1 mg d/l White blood cell count of 11,500 per microliter

Vancomycin trough of 15 mcg/dl Rationale: Vancomycin has a low therapeutic index, with nephrotoxicity and ototoxicity complicating therapy if toxicity develops. In contrast, underdosing (less than the minimum inhibitory concentration) can lead to treatment failure. Nephrotoxicity is associated with a trough level above 10 mcg/dl. The BUN and creatinine in this case are still within a normal range. While the WBC count is elevated, this is an expected finding.

A nurse is preparing to discontinue a client's fentanyl patient-controlled analgesia infusion. Which priority action will the nurse take before discontinuing the infusion? Assess the client's pain level Document the frequency of doses on the medication administration record Take the client's vital signs Verify the infusion record with another registered nurse

Verify the infusion record with another registered nurse Rationale: The nurse should verify the infusion record with another licensed healthcare provider before discontinuation. Fentanyl is a controlled substance that requires recordkeeping of its usage. Assessing the client's pain level and checking vital signs are important assessments; however, these actions are not specific to patient-controlled analgesia with a controlled substance. Documenting the frequency of doses is important but must be verified with another licensed provider.

The nurse is preparing to administer simethicone orally to a postpartum client. Which of the following actions should the nurse take first? Ask the client to state their name Place the medication into a pill cup Collect the medication from the pharmacy Verify the prescription in the medical record

Verify the prescription in the medical record Rationale: When administering any medication, the first thing the nurse should do is verify the prescription in the medical record. Verifying the prescription first helps to avoid the possibility of medication errors. In this case, once the prescription has been verified, the nurse can collect the medication from the pharmacy, verify the client's identification, and then place the tablet in the pill cup for administration.

A client has been admitted for the second time to treat tuberculosis (TB). Which referral does the nurse initiate as a priority? A Social worker to see if the client can afford the medications B Infection control nurse to arrange testing for drug resistance C Psychiatric nurse liaison to assess reasons for noncompliance D Visiting nurses to arrange for directly observed therapy (DOT)

Visiting nurses to arrange for directly observed therapy (DOT) Rationale: Clients with TB must take multiple drugs for six months or longer, making adherence a very real problem. Non-adherence is the most common cause of treatment failure and relapse. This client has a risk of non-adherence, as evidenced because this is their second admission to treat TB. When the client is discharged, they most likely will need to be placed on DOT to ensure compliance. This is the priority referral in order to prevent transmission of TB to others in the community. The other referrals may also be appropriate depending on the client's needs.

The nurse is teaching a client about precautions while taking warfarin. The nurse should instruct the client to avoid foods with excessive amounts of which nutrient? A Vitamin E B Calcium C Iron D Vitamin K

Vitamin K Rationale: Vitamin K is an essential vitamin required for blood clotting. Eating foods with excessive amounts of vitamin K may alter anticoagulant effects. Foods highest in vitamin K include (dried and fresh) herbs, dark leafy greens, scallions, Brussel sprouts, broccoli, chili powder, prunes, asparagus, and cabbage.

A nurse is preparing to administer indomethacin to a client with acute pain. Which medication on the client's medical record will prompt the nurse to monitor the client more frequently? Pantoprazole Warfarin Simvastatin Alprazolam

Warfarin Rationale: Indomethacin is a non-steroidal anti-inflammatory drug (NSAID) used in the treatment of mild to moderate pain. NSAIDS increase the risk of gastrointestinal bleeding. Warfarin is an anticoagulant medication that can increase the risk of bleeding. The nurse should monitor the client for adverse effects more frequently. Pantoprazole is a proton pump inhibitor used in the treatment of gastric ulcers. Simvastatin is an antilipemic medication used in the treatment of high cholesterol. Alprazolam is a benzodiazepine used in the treatment of anxiety. Pantoprazole, simvastatin, and alprazolam have no known drug interaction with indomethacin.

The nurse is teaching a client who uses a wheelchair for mobility about reducing pressure injuries. Which exercise should the nurse include in the teaching? Wheelchair push-ups Leg lifts Ankle rolls Shoulder lifts

Wheelchair push-ups Rationale: When sitting in a wheelchair, the majority of the bodyweight is on the pelvis and the buttocks. These are bony areas that can have skin breakdown if the pressure is not relieved. Wheelchair push-ups take pressure off the bony areas. The other exercises will maintain muscle tone but will not take pressure off the buttocks and pelvis.

The nurse is reviewing the laboratory results for a client with cancer who is being treated with chemotherapy and recently started prescribed filgrastim. Which laboratory value indicates the treatment is effective? Hemoglobin level of 9.8 g/dL White blood cell count (WBC) of 5,200/mm3 Platelet count of 200,000/mm3 Red blood cell count (RBC) of 4 million/mm3

White blood cell count (WBC) of 5,200/mm3 Rationale: The client has a normal white blood cell count indicating that filgrastim has been effective. The action of filgrastim is to increase neutrophil production, thereby increasing the white blood cell (WBC) count. Decreased hemoglobin (Hgb) indicates anemia. The hemoglobin and red blood cell (RBC) count are below normal limits for an adult male. Epoetin alfa is used to treat low RBC counts (anemia) caused by chemotherapy. The platelet count is within normal limits for an adult client.

The nurse is caring for a client receiving total parenteral nutrition (TPN). The TPN has been infusing 24 hours. Which of the following findings requires intervention? Blood sugar is 115 mg/dl White blood cell count is 11,500 Albumin level is 3.7 g/dl Potassium level is 3.6 mmol/l

White blood cell count is 11,500 Rationale: An increase in WBC count is an indication of infection. Dextrose in TPN increases the risk of infection. Assess for signs and symptoms of infections at the site (redness, tenderness, discharge) and systemically (fever, increased WBC, malaise). The site dressing should be dry and intact. Blood glucose, albumin, and potassium are some of the labs that are monitored while a client is on TPN. The results in this example are expected findings.

The nurse is caring for a client who is receiving isoniazid for tuberculosis (TB). Which assessment finding would indicate the client is having a possible adverse response to this medication? A Tinnitus and decreased hearing B Headache and nausea C Tingling in extremities D Yellowing of the sclera

Yellowing of the sclera Rationale: Isoniazid is a first-line anti-tuberculosis drug that is used as part of the combination therapy for the treatment of tuberculosis. These first-line medications may be used for up to 2 years in clients who are being treated for tuberculosis. The use of long-term combination treatment increases the effectiveness and decreases the occurrence of resistant strands. Clients receiving this medication are at risk for drug-induced hepatitis. The appearance of jaundice may indicate an elevation of the client's serum bilirubin levels and liver enzymes (AST and ALT). A small number of clients taking isoniazid develop severe hepatitis that may progress to liver failure and death unless the medication is stopped immediately. Other common side effects include nausea and tingling in the extremities. This medication is not ototoxic and does not affect hearing.

The nurse is assisting a client who is taking amlodipine with meal planning. Which fluid selected by the client would require follow up by the nurse? Black coffee Grapefruit juice Green tea Chocolate Milk

grapefruit juice Rationale: Grapefruit juice affects the metabolism of certain medications, such as amlodipine, and may cause toxicity if taken together. Clients who are taking antibiotics, such as tetracycline, should avoid consuming milk products. Clients who are taking warfarin should avoid consuming green tea. Clients who are taking stimulants should avoid consuming black coffee.

The nurse is preparing to administer prescribed IV pantoprazole to the hospitalized client. The medication has been stocked in tablet form. Which action by the nurse is appropriate? Administer the medication to the client in oral form Call the pharmacy to stock the correct form of the medication Request that the healthcare provider change the order to tablets Ask the pharmacist if it is safe to give the client oral pantoprazole

Call the pharmacy to stock the correct form of the medication Rationale: Safety is of the utmost importance in preparing and administering medications. Suggested rights of administration vary from the classic five rights (listed first) through upward of eleven rights, including right medication, right patient, right dosage, right route, right time, right reason, right assessment data, right documentation, right response, right education, and right to refuse. In this case, the nurse has identified a potential issue with the right route of administration. The nurse should call the pharmacy and have the correct form of the medication provided for administration. Administering the medication by the incorrect route is considered a medication error. The healthcare provider's order is not incorrect, and the safety of administration via this route is not what is in question.

A nurse is assessing a client who received an intravenous fluid bolus for dehydration. Which finding indicates the fluid therapy was effective? Capillary refill of +2 Oxygen saturation of 91% Heart rate of 105 beats/min Urinary output of 25 ml/hr

Capillary refill of +2 Rationale: A capillary refill of +2 is a normal finding and an intended cardiovascular effect of fluid replacement. Oxygen saturation of 91% indicates hypoxia, which occurs with dehydration. Tachycardia is an indication of dehydration. An elevated heart rate is an attempt to maintain normal blood pressure when there is a deficiency in volume. Urinary output of 25 ml/hr is indicative of oliguria, a decreased production of urine. Oliguria occurs with dehydration.

A client is prescribed furosemide and digoxin for heart failure. The nurse should monitor the client for which potential adverse drug effect? A Acute arterial occlusion B Pulmonary hypertension C Acute kidney injury D Cardiac dysrhythmias

Cardiac dysrhythmias Rationale: Digoxin is a cardiac glycoside, or positive inotrope that increases myocardial contractility. By increasing contractile force, digoxin can increase cardiac output in clients with heart failure (HF). Furosemide is a potassium-wasting (loop) diuretic, prescribed to prevent fluid overload in clients with HF. Clients who take furosemide are at risk for developing hypokalemia. Potassium ions compete with digoxin and a low potassium level can cause digoxin toxicity, leading to lethal cardiac dysrhythmias. Therefore, it is imperative that potassium levels be kept within normal range (3.5 to 5 mEq/L) while taking digoxin.

The health care provider orders trazodone ER 150 mg at bedtime. Which common side effect of this drug should the client understand? A Relieves nasal stuffiness B Reduces arthritic pain C Decreases acne breakouts D Causes drowsiness

Causes drowsiness Rationale: Trazodone is an antidepressant medication that produces drowsiness, so it is ordered at bedtime. In addition to treating depression, it targets the symptom of insomnia often experienced by clients who are depressed. Other common side effects of trazodone include dry mouth, stuffy nose, constipation or change in sexual interest/ability. The other choices are not side effects of this medication.

A nurse is assessing a client diagnosed with diabetic ketoacidosis. The client is on a prescribed regular insulin infusion at 0.1 units/kg/hr. The client appears restless and verbalizes tingling to the extremities. Which action does the nurse perform next? Check the client's capillary blood glucose Stop the regular insulin infusion Increase the infusion to 0.15 units/kg/hr Give the client 4 oz of fruit juice

Check the client's capillary blood glucose Rationale: The client is experiencing symptoms of hypoglycemia. Prior to decreasing the dose of the infusion, the nurse should assess the client's blood glucose level to confirm the hypoglycemia. Prior to stopping the infusion, the nurse needs to assess the client's blood sugar level and notify the healthcare provider of the results. Increasing the infusion will cause further hypoglycemia. Prior to performing an intervention to correct the hypoglycemia, the nurse needs to assess the blood glucose level first.

A nurse is reviewing a blood transfusion prescription for a client with esophageal bleeding. Which client safety action will the nurse perform prior to initiating the transfusion? Check the client's record for a signed informed consent Run the blood warmer for at least 10 minutes Ensure the client has at least a 22-gauge intravenous catheter Prime the administration set with normal saline

Check the client's record for a signed informed consent Rationale: An informed consent is required prior to administering blood products to a client. The client must be informed of risks, benefits, and alternatives prior to obtaining signed consent. Blood should be administered through a large-bore IV, ideally an 18-20 gauge. A blood warmer is only used if indicated, not as a standard procedure. Priming the administration set is standard practice. Checking the client's consent form is a safety intervention.

A nurse is preparing to initiate a blood transfusion on a client with anemia. Which step will the nurse perform to prevent a transfusion error? Check the client's wristband against the blood component Verify the blood component independently against the provider's prescription Match the blood component to the client's consent form Place a blood component identification label in the client's medical record

Check the client's wristband against the blood component Rationale: One of the verification steps before a transfusion is to match the client to the blood component. Checking the client's wristband against the blood component verifies the correct client is receiving the transfusion. The verification should be between two people or one person accompanied by automated identification technology such as a bar code. The consent form verifies the client agreed to the transfusion. However, this does not prevent a misidentification error. Placing an identification label in the client's medical record verifies the transfusion occurred but does not prevent a transfusion error.

The nurse is preparing to administer medications to her assigned clients. In order to reduce medication errors, which of the following rights of medication administration should the nurse adhere to? Select all that apply. Place each client's medication on their bedside table during the beginning of shift rounds Check the medication against the medication administration record (MAR) Confirm the client's room number against the medication administration record (MAR) Maintain a distraction-free environment while administering medication Prepare injectable medications at the beginning of the shift before the shift becomes busy Verify the client's full name and date of birth in the medication administration record (MAR) Ensure the medication is in the right form as ordered by the health care provider (HCP)

Check the medication against the medication administration record (MAR) Maintain a distraction-free environment while administering medication Verify the client's full name and date of birth in the medication administration record (MAR) Ensure the medication is in the right form as ordered by the health care provider (HCP) Rationale: Medication safety includes maintaining a culture of safety and ensuring rigorous verification prior to administration. Distraction-free medication administration is recommended as well as checking three times to ensure the correct medication and the rights of medication. The rights of medication include the right medication, client, dosage, form, route, timing, and indication. Medication should be prepared at the time of administration and never left unattended by the nurse. These safeguards help reduce medication errors.

A nurse is assessing a client with a continuous intravenous infusion. The nurse notes the infusion pump frequently alerts, pauses, and then restarts. Which action should the nurse perform first? Check the tubing for any kinks Replace the infusion pump Initiate intravenous access in a new location Flush the line with normal saline

Check the tubing for any kinks Rationale: The nurse should ensure the intravenous tubing is not bent or kinked. An alert followed by a pause indicates the fluid is not flowing adequately. This is commonly due to an occlusion. The nurse should troubleshoot the infusion before replacing the equipment. Initiating new intravenous access is not indicated unless the current access site is not functional. There is no indication the current access is not functioning. Flushing the line assesses for adequate flow. However, the nurse should first assess for any external occlusions.

A nurse is reviewing prescriptions for a client with a history of rheumatoid arthritis and peptic ulcer disease. The client has prescriptions for ibuprofen and ranitidine. Which action will the nurse perform? Clarify the prescription for ibuprofen Administer the ibuprofen 30 minutes before the ranitidine Hold the ranitidine for 1 hour after meals Question the prescription for ranitidine

Clarify the prescription for ibuprofen Rationale: Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal (GI) bleeding. The client has a history of peptic ulcer disease. The nurse should clarify the prescription for ibuprofen. Administering the ibuprofen before the ranitidine does not address the issue of possible GI bleeding. Ranitidine can be administered without regard to meals. The prescription for ranitidine is appropriate for the client's condition and does not need to be questioned.

A nurse is providing care to an older adult client with newly diagnosed heart failure. The nurse receives a prescription for digoxin PO 1.5 mg daily. Which action does the nurse perform next? Instruct the client to take the heart rate before administration Educate the client on the purpose of digoxin Administer the medication to the client Clarify the prescription with the healthcare provider

Clarify the prescription with the healthcare provider Rationale: Older adult clients (geriatric) have a high sensitivity to the toxic effects of digoxin. A dose of 1.5 mg daily is above the recommended range for adults. The initial daily dose for a geriatric client should not exceed 0.125 mg. Educating the client on the purpose of digoxin and performing related assessments are expected interventions. However, the nurse should clarify the dose first. Administering the prescribed medication dose to the client may result in significant side effects.

During morning rounds, a healthcare provider informs a client with hypertension that a calcium channel blocker will be added to their treatment regimen. The nurse notes a new prescription for amiloride 10 mg PO daily. Which action does the nurse perform next? Clarify the prescription with the healthcare provider Educate the client on the new prescription Administer the medication with food Assess the client's blood pressure

Clarify the prescription with the healthcare provider Rationale: The nurse should clarify the new prescription. Amiloride is a potassium-sparing diuretic. It is also a look-alike/sound-alike medication commonly confused with amlodipine, a calcium channel blocker. Educating the client on a new prescription, administering the medication with food, and assessing the blood pressure are important interventions for amiloride. However, this prescription should be clarified.

A nurse is reviewing new prescriptions for a client diagnosed with heart failure. The nurse notes captopril 25mg PO. Which action does the nurse perform next? Administer the medication before meals Clarify the prescription with the healthcare provider Take the client's weight Check the client's latest creatinine level

Clarify the prescription with the healthcare provider Rationale: The nurse should clarify the prescription with the healthcare provider. The prescription is missing a frequency, a necessary component of a medication prescription. Captopril should be administered before or after meals. However, the prescription does not have a frequency and should be clarified. Taking the client's weight and checking renal labs are important interventions after the prescription is clarified.

The nurse is performing triage on clients during a facility disaster drill. Which of the following indicates correct understanding of disaster triage? Classifying a client with a pneumothorax as emergent Classifying a client with a cervical spinal cord injury as urgent Classifying a client with an open femur fracture as non-urgent Classifying a client with a scalp laceration as expectant

Classifying a client with a pneumothorax as emergent Rationale: In mass casualty disaster situations, triage focuses on doing the greatest good for the greatest number of people. Therefore, when resources are severely limited, some clients who have very extensive critical injuries who would otherwise receive massive resuscitation efforts (cervical cord injury, head injuries, massive burns), may be classified as expectant, or black-tagged and allowed to die or not be treated. Clients with airway compromise or shock are classified as emergent and are seen immediately. Clients with open fractures or wounds should be classified as urgent and seen within 30 minutes to 2 hours. Clients with abrasions or contusions should be classified as non-urgent and can be seen after 2 hours or when other more urgent clients have been attended to.

A nurse is evaluating a client who takes naproxen for pain associated with osteoarthritis. Which documented statement indicates the expected outcome was met? Decreased erythema noted to joints Muscle strength 3/5 to lower extremities Client observed with steady gait upon ambulation Deep tendon reflexes +3

Client observed with steady gait upon ambulation Rationale: The observation of a steady gait while ambulating indicates the relief of pain associated with osteoarthritis. Osteoarthritis causes limping due to knee and/or hip pain. Erythema of the joints is associated with rheumatoid arthritis and does not indicate pain relief. A muscle strength of 3/5 indicates muscle atrophy and is not an expected outcome of the medication. Brisk reflexes are not associated with osteoarthritis or the intended effect of the medication.

The nurse is caring for clients on the medical unit when the "Code Red" alert is announced over the intercom. The unit is not close to the fire's point of origin. Which of the following actions is appropriate? Close the double doors to the unit Assist all clients to the far end of the unit Use the elevators to begin the evacuation Relocate clients to a unit on a higher floor

Close the double doors to the unit Rationale: Upon activation of a code red, nurses who are not in proximity to the fire should first close all doors and keep patients and visitors in their rooms with the doors closed. Elevators may be unsafe, and clients would be evacuated using the stairwell. Clients are not relocated to higher floors during fires. Evacuation will occur horizontally, and then laterally, if there is immediate danger due to fire, smoke, chemical release, structural failure, or a similar condition.

The nurse is preparing to administer an intravenous medication to a client who is obtunded. What action is appropriate to confirm the client's identity? Wake the client and ask them to state their name Use the room number as an identifier Compare the armband to the medical record Ask the previous nurse to confirm the client's identity

Compare the armband to the medical record Rationale: As part of the rights of medication administration, the nurse should identify a client by checking the name and record number on the wristband and comparing it to the health record. The nurse should not ask the client with a decreased level of consciousness for their name because it is not reliable information and/or the client may be unable to self-report. Obtundation means that the client only remains awake when stimuli are applied. The client is often confused when awake. The room number should not be used as an identifier as room assignments often change. Other staff should not be used to confirm identity.

The nurse is caring for a client with a diagnosis of cardiogenic shock who has been prescribed dobutamine infusion. Which action should the nurse take first? Compare the packaging of the medication to the prescription Prime the IV tubing with the medication Set the infusion pump for the correct infusion rate Increase the frequency of blood pressure and heart rate monitoring on the bedside monitor

Compare the packaging of the medication to the prescription Rationale: The Food and Drug Administration and Institute for Safe Medication Practices has maintained a list of drug name pairs and trios that look and sound similar. These medications are called out with tall man lettering on dissimilar lettering on the packaging (capital letters). Dobutamine is often confused with dopamine and is included in the list. Ensuring the use of the right medication is a part of the rights of medication administration. This should be done before priming the tubing with the medication and setting the infusion pump. While frequent vital signs are important for the client with shock, it isn't the most important action in this scenario.

The nurse administers medication to the wrong client. Which action(s) should the nurse take when the medication error is identified? Select all that apply. Complete an incident report Administer ipecac syrup to the client Report the error to the board of nursing Document the error in the medical record Notify the health care provider Monitor the client for adverse effects

Complete an incident report Document the error in the medical record Notify the health care provider Monitor the client for adverse effects Rationale: When a medication error occurs, the nurse should notify the health care provider (HCP) immediately. Giving the wrong medication to a client may cause adverse effects, and the nurse should monitor the client closely for the appropriate length of time. The administration of ipecac syrup to induce vomiting is not recommended after the occurrence of a medication error. The nurse is required to document the medication error and follow-up interventions in the client's medical record. An incident report regarding the medication error needs to be completed as well. The report allows the nurse and health care facility to investigate the root cause for the medication error and put measures in place to prevent future errors. Reporting the error to the board of nursing (BON) is not required.

The nurse is monitoring an older adult client prescribed diphenhydramine for contact dermatitis related to poison ivy exposure. Which finding should be reported to the provider as a potential drug-related side effect? Confusion Hypertension Incontinence Bradypnea

Confusion Rationale: Diphenhydramine and other first-generation H1 receptor antagonists may cause confusion (with impaired thinking, judgment, and memory), dizziness, hypotension, sedation, syncope, unsteady gait, and paradoxical central nervous system stimulation in older adults. Older adults may experience urinary retention, especially those with prostatic hypertrophy. Some of these adverse reactions derive from the anticholinergic effects of the drugs and are likely to be more severe if the patient is also taking other drugs with anticholinergic effects. Diphenhydramine is sometimes prescribed as a sleep aid for occasional use in older adults. As with many other drugs, smaller-than-usual dosages are indicated.

A nurse is preparing to administer intravenous mannitol to a client with increased intracranial pressure. Which action will the nurse perform prior to administering the medication? Connect an in-line filter to the infusion tubing Dilute the medication with lactated ringers Prepare an infusion warmer Ensure the client has a patent central line

Connect an in-line filter to the infusion tubing Rationale: The nurse should connect a filter to the infusion tubing prior to administering mannitol. Mannitol is an osmotic diuretic that may contain crystals within the solution. The in-line filter prevents the administration of particulates into the bloodstream. Mannitol should be administered undiluted. An infusion warmer is not required for the administration of mannitol. Mannitol can be administered through a peripheral line.

A nurse is educating a client about the use of warfarin at home. The nurse should reinforce the need for the client to monitor which of the following? A Avoidance of public transportation and large groups of people B Extended exposure to outdoor sunlight C Limit of strenuous physical exercise D Consistent intake of foods high in vitamin K

Consistent intake of foods high in vitamin K Rationale: Warfarin, an oral anticoagulant, works by causing a decrease in the vitamin K-dependent clotting factors produced by the liver. Due to this mechanism of action, vitamin K is used as the antidote for warfarin overdose. A diet high in vitamin K could counteract the therapeutic effect of warfarin. Foods high in vitamin K include dark green leafy vegetables, tomatoes, bananas, cheese and fish. Best practice no longer recommends limiting the intake of Vitamin K-containing foods, instead it is recommended to keep the intake of foods high in Vitamin K 'consistent'. The other actions do not pertain to warfarin.

The nurse is preparing to administer prescribed digoxin to client with atrial fibrillation. The nurse notes the packaging for the medication is provided in a different route than prescribed. Which action should the nurse take? Administer the medication as ordered Consult the pharmacist regarding the error Alert the charge nurse to the medication error Contact the health care provider

Consult the pharmacist regarding the error Rationale: Careful consultation with a pharmacist regarding the error is the most appropriate action for the nurse to take if an error occurs when the pharmacy dispenses the medication. The medication as provided by the pharmacy is incorrect and cannot be administered. The charge nurse may be alerted, but the pharmacy can correct the error.

A nurse is reviewing prescriptions for a post-operative client. The nurse notes "resume previous medications" on the client's record. Which action does the nurse perform? Verify the medications on the client's medication administration record Notify the pharmacy to dispense the client's previous medications Contact the healthcare provider for new medication prescriptions Ask the client to provide a list of all home medications

Contact the healthcare provider for new medication prescriptions Rationale: The nurse should contact the healthcare provider to re-write all medication prescriptions. Blanket orders such as "resume previous medications" are not acceptable practice after a client has had surgery and their condition has changed. Verifying the medications on the client's medication administration record is good practice. However, the prescriptions need to be re-ordered. Notifying the pharmacy to dispense the client's previous medications is not indicated. The pharmacy will require new medication prescriptions. Asking the client to provide a list of all home medications should be performed upon admission.

The nurse observes that a client whose blood type is AB-negative is receiving a transfusion of O-negative packed red blood cells. Which action should the nurse take? Stop the transfusion immediately. Administer prescribed diphenhydramine. Continue to monitor the client. Report the problem to the blood bank.

Continue to monitor the client. Rationale: Clients with an AB-negative blood type can receive O-negative blood because they do not have antibodies against this type of blood. O-negative blood is also called the "universal donor" blood type. The transfusion can proceed and the nurse should continue to monitor the client. The blood bank would not need to be called and diphenhydramine (Benadryl) would only be given if the client is having an allergic reaction.

The nurse is preparing to administer newly prescribed intravenous phenytoin to a client. When reviewing the client's medical record, which prescription should the nurse question? Continuous infusion of dextrose 5% in 0.9% saline NPH insulin 40 units before meals Labetalol 100 mg orally twice per day Ketorolac 15 mg IV push as needed for pain

Continuous infusion of dextrose 5% in 0.9% saline Rationale: Phenytoin is not compatible with most IV fluids, especially those with dextrose. If the nurse observes a continuous infusion of a fluid that contains dextrose, they should understand that incompatibilities are likely and should not administer the medication as prescribed. Insulin, labetalol, and ketorolac do not have potential incompatibilities.

A nurse is assessing a client receiving an intravenous fluid bolus. Which clinical finding indicates an adverse effect to the fluid therapy? Crackles auscultated in the lungs Urine output of 100 mL in an hour Decreased skin turgor Heart rate of 98 beats/min

Crackles auscultated in the lungs Rationale: Crackles upon auscultation of the lungs can be an indication of fluid overload. A bolus is a rapid administration of fluid, which should be carefully monitored. A urine output of 100 mL in one hour is not indicative of an adverse effect to fluid therapy. An increase in urine output is expected. Decreased skin turgor is an indication of dehydration, not an adverse effect to fluid replacement. A heart rate of 98 beats/min is on the higher side of normal (60-100 beats/min).

The nurse is assessing a client who is taking rifampin for the treatment of tuberculosis. Which finding reported by the client should the nurse immediately report to the healthcare provider? Blurred vision Orange-tinged tears Dark amber urine Diarrhea

Dark amber urine Rationale: Rifampin causes a temporary yellow-orange discoloration of body fluids. Soft contact lenses may be permanently stained. Dark amber urine is an indication of liver dysfunction and should be reported. A major adverse effect of ethambutol, not rifampin, is optic neuritis. Diarrhea is a common side effect of antibiotics and is not the priority in this case.

The nurse is caring for a client with cachexia who has delayed wound healing and has been prescribed total parenteral nutrition (TPN). Which of the following findings indicates that the TPN is having the intended effect? Decreased wound measurements Dark red color around the edges Serous drainage from the wound Increased pain

Decreased wound measurements Rationale: Decreasing wound measurements are one indication of wound healing. Normally, the healing process occurs without assistance; however, a variety of factors affect wound healing, including nutritional status. Wound healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals. Clients who are undernourished may lack the nutritional stores to promote wound healing. TPN can support the nutritional needs of a client who cannot tolerate enteral feeding and is experiencing the adverse effects of malnutrition. Dark red wound edges, drainage, and pain are all indications of impaired wound healing.

The nurse is caring for the client with a triple lumen central venous access device prescribed total parenteral nutrition (TPN). Which of the following actions is appropriate? Dedicate one lumen to TPN administration Initiate the infusion at the goal infusion rate Add a .22-micron filter to the infusion set Change the infusion set every 96 hours

Dedicate one lumen to TPN administration Rationale: TPN is administered using an electronic infusion device with anti-free-flow protection, via continuous or cyclic infusion. If the patient has a multilumen catheter in place, dedicate one lumen for the administration of the parenteral nutrition. Do not use that lumen or administration set for any other purpose to prevent incompatibility problems. Use a 1.2-micron filter for total nutrient admixtures (3-in-1, all-in-one). Change infusion administration sets every 24 hours. TPN should be initiated slowly and titrated up to reduce swings in blood sugar.

A nurse is assessing a client who is receiving IV intermittent fluid replacements. Which finding indicates the client is experiencing fluid volume excess? Neck veins appear full when client is supine. The client is lethargic. Dark yellow urine is present. Dependent edema is present in bilateral lower extremities.

Dependent edema is present in bilateral lower extremities. Rationale: Edema to bilateral lower extremities is indicative of fluid overload and fluid retention. The nurse should report this finding to the healthcare provider. Full neck veins when the client is supine is a normal finding. Distended neck veins when the client is upright is a cause for concern. Lethargy is a sign of severe fluid volume deficit. Dark yellow urine is indicative of extracellular volume deficit. The kidneys will attempt to reduce urine production to maintain volume.

The nurse is reviewing the client's medical record and notes that the client has been taking an oral contraceptive for several years. For which potential complications should the nurse monitor the client? Select all that apply. Depression Colon Cancer Osteoporosis Breast cancer Deep Vein Thrombosis (DVT) Anemia

Depression Breast cancer Deep Vein Thrombosis (DVT) Rationale: Oral contraceptives contain both advantages and disadvantages for clients. Advantages include shortening menstrual cycles, decreasing anemia and protecting against bone loss. Clients have decreased risks for ovarian, colorectal and endometrial cancers. Potential complications include increased risks for breast cancer, depression and a DVT. Women who smoke may have an increased risk for myocardial infarction, stroke and hypertension.

The nurse is monitoring the client who is taking newly prescribed antihypertensive medication. Which finding should indicate to the nurse that the client might be experiencing an allergic reaction to the medication? Mild decrease in blood pressure Increased urine output Left-sided weakness Development of a rash

Development of a rash Rationale: Allergic reactions are often manifested by the presence of a rash, urticaria, gastrointestinal symptoms, and itching. A mild decrease in blood pressure is the intended effect of the medication. Increased urinary output and unilateral weakness are not indications of an allergic reaction.

A nurse is preparing to administer morning medications to a client with heart failure. The morning lab values are: sodium 142 mEq/L (142 mmol/L), potassium 2.9 mEq/L (2.9 mmol/L), digoxin level 1.4 ng/mL. Which of the following medications should the nurse not administer until after speaking with the health care provider? A Spironolactone B Carvedilol (Coreg) C Ferrous sulfate D Digoxin (Lanoxin)

Digoxin (Lanoxin) Rationale: Because the potassium levels are low (normal is 3.5 to 5 mEq/L or 3.5 to 5 mmol/L), the nurse should not give the digoxin; hypokalemia can predispose a person to digoxin toxicity. The other medications can be administered. Although carvedilol can increase plasma digoxin concentration, the digoxin level is normal. Spironolactone is a potassium-sparing diuretic and because the potassium level is low, this too can be given. Ferrous sulfate does not affect the given lab values.

A nurse is preparing to administer a hydromorphone injection to a client. As the nurse begins to connect the syringe to the intravenous port, the client refuses the medication. Which action does the nurse perform next? Discard the medication in the presence of another nurse Dispose of the syringe in the sharps container Flush the unused medication in the sink Document the client's refusal of the medication in the electronic record

Discard the medication in the presence of another nurse Rationale: Hydromorphone is a controlled substance that is regulated by federal law. Any unused medication should be discarded in the presence of another licensed provider. The medication in the syringe should be discarded before disposing of the supplies. The medication should be flushed according to policy; however, it should be performed in the presence of another licensed provider. Documenting refusal of medications is an important nursing action; however, this should be done after the medication is discarded according to policy.

The nurse is caring for a client receiving a prescribed infusion of total parenteral nutrition (TPN). Which of the following actions is appropriate? Monitor blood glucose levels daily Discard the remaining TPN solution after 24 hours Change the transparent dressing every 48 hours Review the provider's order weekly

Discard the remaining TPN solution after 24 hours Rationale: TPN orders should be reviewed each day so that changes in electrolytes or the acid-base balance can be addressed appropriately without wasting costly TPN solutions. Blood glucose levels should be monitored 4 times a day initially to monitor for glycemic control. Generally, new TPN tubing is required every 24 hours to prevent catheter-related bacteremia. Any TPN remaining should be discarded and a new bag be hung. Transparent dressings may remain in place for up to 7 days. Gauze dressings are changed every 48 hours.

A nurse is preparing to withdraw insulin into a syringe in the medication room. The nurse notes an open, full vial of regular insulin with no labeled expiration date. Which action does the nurse take? Discard the vial and request a new one from the pharmacy Label the vial with the current date and withdraw the medication Withdraw the medication and discard the vial Store the medication in the refrigerator and notify the pharmacy

Discard the vial and request a new one from the pharmacy Rationale: Opened vials of medication should have a labeled expiration date. Multi-dose vials expire 28 days after being opened. The nurse should discard the vial and request a new one since there is no way of knowing when the vial was opened. Labeling the medication with the current date or withdrawing the medication are not safe practices. There is no way to verify how long the medication has been opened. The vial should not be stored without an expiration date label.

A nurse is assessing a client receiving intravenous potassium chloride. The client verbalizes pain to the IV site. The site appears swollen and is warm to touch. Which action does the nurse perform? Decrease the rate of the infusion Apply ice to the IV access site Inform the client that this is an expected finding Discontinue the IV catheter

Discontinue the IV catheter Rationale: The nurse should discontinue the IV catheter. The client's symptoms are indicative of phlebitis, inflammation of the vein. Decreasing the rate of the infusion will not treat the swelling or injury to the vein. Applying ice to the access site does not address the possible vein injury caused by the medication. Pain, swelling, and warmth are not expected findings for a patent IV access site.

The nurse is assessing a postpartum client who is taking labetalol. Which client report should the nurse identify as a potential adverse effect of the medication? Nausea Ankle edema Abdominal pain Dizziness

Dizziness Rationale: Labetalol is a beta-blocker that is used for blood pressure management in postpartum clients. The mechanism of action for labetalol is to vasodilate, which could lead to a decrease in blood pressure. A client with a sudden drop in blood pressure could report dizziness. Report of nausea or ankle edema is normal during pregnancy. Abdominal pain in pregnancy could be from active labor or constipation.

The nurse is teaching a client about some of the side effects of fluoxetine. What information should the nurse be certain to include? A Tachycardia, blurred vision, hypotension, anorexia B Orthostatic hypotension, vertigo, hunger, reactions to tyramine-rich foods C Photosensitivity, seizures, edema, hyperglycemia D Drowsiness, dry mouth, changes in weight or appetite, reduced libido

Drowsiness, dry mouth, changes in weight or appetite, reduced libido Rationale: Fluoxetine (Prozac) is an antidepressant in a group of drugs called selective serotonin reuptake inhibitors (SSRIs). Commonly reported side effects include drowsiness and yawning, dry mouth, changes in weight or appetite, and sexual dysfunction; other reported side effects include insomnia and strange dreams, stuffy nose or tremors. People taking MAOIs should avoid foods containing tyramine. Tricyclic antidepressants (TCAs) can cause photosensitivity and TCA toxicity can cause hypotension and cardiac dysrhythmias.

A client is taking diphenhydramine for seasonal allergic rhinitis. The nurse should reinforce teaching for the client about which possible side effects? Select all that apply. Dry mouth Urinary frequency Constipation Drowsiness Urinary retention

Dry mouth Constipation Drowsiness Urinary retention Rationale: Diphenhydramine is an over-the-counter (OTC) drug commonly used for allergic rhinitis and the common cold. It is a first-generation H1 antagonist or antihistamine. Sedation and sleepiness are the most common side effects of this antihistamine. Due to the anticholinergic effects of H1 blockers, constipation, dry mouth, and urinary retention are potential side effects. Urinary frequency is not an expected finding.

The client voices concern and refuses to take the medication. What actions should the nurse take? Select all that apply. Ask the client's significant other for permission to give the medication Notify the pharmacist to discontinue the medication Ask the client if they prefer the medication in an oral form Ensure the client correctly understands the medication's purpose Confirm the client understands the risks associated with not taking the medication Clarify the reason why the client is refusing the medication

Ensure the client correctly understands the medication's purpose Confirm the client understands the risks associated with not taking the medication Clarify the reason why the client is refusing the medication Rationale: The client has a right to refuse any medication or treatment. If the client refuses a medication, the nurse should identify the reason for refusal and ensure the client understands the purpose of the medication and the potential risks of not taking the medication. Refusing the enoxaparin places the client at an increased risk for developing a venous thromboembolism (VTE). The ordering health care provider (HCP) is the only person who can discontinue the medication. Enoxaparin is only available to be given as a subcutaneous injection.

A nurse is preparing to administer prescribed maintenance dose of digoxin to a client who has heart failure. Which action should the nurse to take? Withhold the medication if the heart rate is above 100/min Instruct the client to eat foods that are low in potassium Measure apical pulse rate for 30 seconds before administration Evaluate the client for nausea, vomiting, and anorexia

Evaluate the client for nausea, vomiting, and anorexia Rationale: A client with heart failure who is prescribed digoxin should be assessed for digoxin toxicity. Manifestations of digoxin toxicity include nausea, vomiting, and anorexia. Digoxin is used to decrease heart rate and should be held if the heart rate is less than 60 beats per minute. Digoxin toxicity can occur when the client has low potassium. When administering digoxin, the nurse should measure the client's apical pulse for a full minute.

The nurse is developing a plan of care for a client who has developed blisters and sores in the mouth after receiving chemotherapy. Which interventions should the nurse include? Select all that apply. Examine your mouth frequently Visit a dental hygienist weekly Drink 2 or more liters of water per day Suck on ice chips during chemotherapy Avoid spicy or acidic foods Use strong mouthwashes to kill bacteria

Examine your mouth frequently Drink 2 or more liters of water per day Suck on ice chips during chemotherapy Avoid spicy or acidic foods Rationale: Mucositis is a complex, multiphase process at the cellular level started in response to cytotoxic chemotherapy. The epithelial cells in the mouth are very sensitive to chemotherapy due to their high rate of cell turnover. Oral cryotherapy using ice water or ice chips can be used for the prevention of mucositis. It is believed that vasoconstriction caused by the cold temperature decreases exposure of the oral mucous membranes to the mucositis-causing agents. Frequent mouth assessment and good and frequent oral hygiene are key in managing mucositis. The client should avoid the use of "strong" mouthwashes that often contain alcohol. Mucositis can be managed at home and does not require seeing a dental hygienist. Increased hydration is generally recommended.

A nurse is reviewing analgesic prescriptions for a client with a history of liver cirrhosis. The prescriptions state to administer PRN for pain. Which medication is the nurse most likely to administer to this client? Fentanyl Acetaminophen Ibuprofen Ketorolac

Fentanyl Rationale: The nurse is most likely to administer fentanyl to a client with liver disease. Fentanyl is an opioid analgesic with a short duration. The medication should be used cautiously in hepatic disease but is not contraindicated. Acetaminophen is highly metabolized by the liver and is contraindicated in clients with active liver disease. Ibuprofen and ketorolac are non-steroidal anti-inflammatory medications that may cause gastrointestinal bleeding. A client with liver disease is at risk for bleeding.

A nurse is preparing a client for a 12-lead electrocardiogram. Which anatomical site indicates correct placement of the electrodes? Fourth intercostal space, left sternal border, to obtain lead V3 Left midaxillary line, third intercostal space, to obtain lead V6 Fifth intercostal space, left midclavicular line, to obtain lead V4 Right sternal border, second intercostal space, to obtain lead V1

Fifth intercostal space, left midclavicular line, to obtain lead V4 Rationale: An electrocardiogram monitors the electrical activity of the heart. The placement of leads is important to obtain accurate readings. Lead V4 provides information on the anterior myocardial wall. The electrode should be placed in the 5th intercostal space (ICS), left midclavicular line. The 4th ICS, left sternal border, corresponds with lead V2. Lead V6 requires an electrode to be placed on the left midaxillary line, 5th ICS. Lead V1 is obtained by placing an electrode on the right sternal border, 4th ICS.

A nurse initiates a continuous IV infusion on a client. An hour later, the nurse notes the IV solution bag contains the same volume as when therapy was first initiated. Which action does the nurse take? Bolus the fluid that was not infused Initiate a new IV access Flush the IV site with normal saline Raise the fluid bag higher on the infusion pole

Flush the IV site with normal saline Rationale: The nurse should flush the IV line with normal saline. The fluid has not infused, indicating there is an obstruction in the tubing or the catheter is no longer functional. A fluid bolus requires a prescription. The nurse should adjust the intake and output on the client's record. Initiating a new IV access is not indicated at this time. The catheter should first be checked for any occlusions. Raising the fluid bag will not address the concern. While gravity can assist with the flow of the infusion, the catheter needs to be checked for occlusions.

A nurse is administering multiple IV push medications to a client through a subclavian central line. Which action will the nurse perform to prevent occlusion of the catheter? Flush the line between each medication Clamp the line after administering the medications Clean the catheter hub for 10 seconds between medication syringes Use a 1-ml syringe to flush the line

Flush the line between each medication Rationale: Intravenous medications have different viscosities. Flushing the line between each medication administration helps to prevent the formation of a thrombus, precipitate, or occluding particles. Clamping the line after administering medications prevents a pneumothorax. Cleaning the catheter hub between syringes prevents infection, not occlusion. Syringes should ideally be 10-ml to avoid excess pressure and damage to the catheter.

The nurse is administering an intravenous push medication through a client's peripheral IV site. Which of the following actions by the nurse is appropriate? Insert the medication into the client's maintenance IV fluids Remove the transparent dressing from the IV site Aspirate blood from the IV site after administration Flush the peripheral IV prior to administration

Flush the peripheral IV prior to administration Rationale: Prior to administering an IV push medication, the line should be flushed to ensure patency. Aspiration of blood can be done before administration. but doing this action after administration increases the risk for occlusion. Inserting the medication into the maintenance fluids slows the administration down significantly; if the medication needs to be diluted, it should be added to a secondary IV bag. The transparent dressing should not be removed unless the intention is to replace the dressing or discontinue the IV.

A 2 year-old child is being treated with amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 33 lb (15 kg) and the daily dose range is 20 to 40 mg/kg of body weight, in three divided doses every eight hours. Using principles of safe drug administration, what should a nurse do next? A Hold the medication because the dosage is too low B Recognize that antibiotics are over-prescribed C Call the health care provider to clarify the dose D Give the medication as ordered

Give the medication as ordered Rationale: Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The dose range is 20 to 40 mg/kg/day divided every eight hours; 15 kg x 40 mg = 600 mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered.

The nurse is caring for a client who was recently prescribed atropine as a treatment for symptomatic bradycardia. Which condition should the nurse question as a contraindication when taking this medication? Urinary incontinence Increased intracranial pressure Right-sided heart failure Glaucoma

Glaucoma Rationale: The nurse should question the use of atropine with a client who has glaucoma. Atropine is contraindicated in clients with angle-closure glaucoma because it can cause pupillary dilation with an increase in aqueous humor. This can lead to an increase in optic pressure causing blurred vision and ocular pain.

A nurse is reviewing prescribed medications for a client diagnosed with diabetic ketoacidosis. Which medication will the nurse clarify with the healthcare provider? Regular insulin Potassium 0.9% sodium chloride Glipizide

Glipizide Rationale: Glipizide is an oral antidiabetic medication used in the treatment of type 2 diabetes mellitus. The intended effect of glipizide is to lower glucose levels and maintain adequate management of the disease. Oral antidiabetic agents are contraindicated in clients with diabetic ketoacidosis (DKA). Glucose levels must be carefully lowered and monitored following insulin therapy. Regular insulin, potassium, and 0.9% sodium chloride are all expected pharmacological treatments for DKA.

A client with a history of chronic kidney disease is prescribed an antibiotic prior to discharge. Which lab findings should the nurse monitor to detect adverse reactions to the medication? Glomerular filtration rate (GFR) Color of urine Urine specific gravity Urine osmolality

Glomerular filtration rate (GFR) Rationale: Patients with chronic kidney disease will have a diminished ability to excrete medications. Monitoring the GFR is the best marker to monitor kidney function. The color of urine does not necessarily correlate with kidney function. Urine specific gravity and urine osmolality measure urine concentration and are used to assess renal disorders of urinary concentration and status of fluid hydration.

The nurse is caring for a client prescribed warfarin therapy for treatment of persistent atrial fibrillation. Which of the following may potentiate the effect of this medication? St. John's wort Estrogen Vitamin K Green tea

Green tea Rationale: Warfarin, an anticoagulant agent used to prevent thrombosis and risk of stroke in clients with atrial fibrillation, is associated with many drug and food interactions. Careful assessment with a pharmacist/formulary is recommended to avoid potential complications. Green tea can potentiate the effect of warfarin and increase bleeding. St. John's wort, estrogen, and vitamin K may inhibit the action requiring higher doses of the anticoagulant.

The nurse is caring for a client with Parkinson's disease. Which finding indicates that the client might be experiencing an adverse side effect from the dopamine-enhancing drugs? A Hypertensive urgency B Urinary retention C Kidney failure D Hallucinations

Hallucinations Rationale: Carbidopa-levodopa-entacapone is the treatment of choice for clients with Parkinson's disease. Common side effects include dyskinesia, confusion and dizziness. Serious side effects include hallucinations, paranoia and agitation. Hallucinations may be relieved by decreasing the dose of levodopa, but this may decrease the effect of the drug on the motor symptoms of Parkinson's disease.

The nurse is caring for a client who received the first dose of fluphenazine two hours ago. The client suddenly experiences torticollis and involuntary spastic muscle movement. After administering the ordered anticholinergic drug, which of the following actions should the nurse implement? A Immediately place the client in a seclusion room B Administer a prn dose of an anti-psychotic medication C Assess the client for anxiety and agitation D Have respiratory support equipment available

Have respiratory support equipment available Rationale: Clients who receive neuroleptic medication and experience torticollis and involuntary muscle movement are demonstrating side effects that could lead to respiratory failure.

There is an order to administer an intramuscular influenza vaccine to an adult client. What actions should the nurse take before administration of the injection? Select all that apply. Record the client's reaction to the injection Have the client sign the vaccination consent form Provide the client with the a vaccine information statement Check the expiration date on the vaccination bottle Ask if the client ever had an adverse reaction to the flu vaccine Record the site and time of injection Record the site and time of injection

Have the client sign the vaccination consent form Provide the client with the a vaccine information statement Check the expiration date on the vaccination bottle Ask if the client ever had an adverse reaction to the flu vaccine Rationale: Prior to administration, the nurse should identify the expiration date on the bottle and give a current copy of the vaccine information statement to the client. The nurse should also verify any allergies or previous reactions to the vaccine, prior to administering the vaccine. A signed consent is required for vaccinations. Observing for a reaction to the injection and recording the site and time of injection should be performed after administering the vaccine.

The nurse is monitoring a client who is taking newly prescribed phenelzine for depression. Which finding reported by the client would indicate the client is experiencing an adverse effect of the mediation? Constipation Dry mouth Headache Muscle fatigue

Headache Rationale: Clients that are prescribed an MAO-inhibitor, such as phenelzine, could experience the adverse effect of hypertension. The client should be assessed for sudden onset of headache, tachycardia, or neck stiffness. Dry mouth, muscle fatigue, and constipation are common side effects of the medication but not the priority for the nurse.

A client who has returned from surgery reports feeling nauseated and later has an emesis. The nurse administers promethazine per standing orders. In addition to relief from nausea, what other effects of this medication does the nurse expect? Select all that apply. Heart palpitations Dry mouth Rhinorrhea Pinpoint pupils Sedation

Heart palpitations Dry mouth Rationale: Promethazine is used as an antihistamine, sedative and antiemetic. It produces anticholinergic effects, such as dry mouth and reduced nasal congestion, dilated pupils and urinary retention. Although promethazine is a sedative, the nurse should understand that it can cause some people to have heart palpitations and to feel restless and unable to sleep.

The nurse is assessing a client who began taking omeprazole a month ago. Which finding by the nurse, indicates that the drug has had the desired effect? A Feelings of depression are not as severe B Blood pressure readings are lower C Chronic pain level is markedly decreased D Heartburn discomfort is lessened

Heartburn discomfort is lessened Rationale: Omeprazole is a proton pump inhibitor used to decrease stomach acid and relieve symptoms of gastroesophageal reflux disorder (GERD), such as heartburn. Omeprazole is also used to treat gastric ulcers and esophagitis. Omeprazole does not affect blood pressure. A lower blood pressure reading in this client would not be related to administration of medication. Omeprazole is not indicated for depression. Although omeprazole can alleviate abdominal pain in an individual who has a gastric ulcer or suffers from gastric bleeding, the option does not specify what type of pain is being discussed. Secondly, omeprazole is not typically indicated for chronic pain. The desired outcome for this client is to have a decrease in symptoms of GERD within 4 weeks.

The nurse is monitoring a client who received a first dose of intravenous ampicillin. Which finding should indicate to the nurse that the client may be experiencing an allergic reaction? Abdominal pain Increase in blood pressure Hypotensive bowel sounds Hives on the extremities

Hives on the extremities Rationale: If the client experiences an allergic reaction to medications they may display systemic signs such as hives, pruritus, dyspnea, etc. Abdominal pain, hypertension, and hyperactive bowel sounds do not indicate an allergic reaction.

The nurse is planning to administer otic drops to a 6-year-old child. Which action is part of the correct procedure? A Insert cotton in the inner ear after giving medication B Place several drops in the outer ear C Assist the child to lie on the affected side afterward D Hold the pinna up and back to instill the drops

Hold the pinna up and back to instill the drops Rationale: The external auditory canal should be straightened by gently pulling the pinna up and back for otic drop administration. In children who are under three years of age, the pinna should be pulled down and back.

The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings indicates the client is experiencing an adverse effect from the TPN? Hypophosphatemia Hyperglycemia Hypokalemia Hyperuricemia

Hyperglycemia Rationale: Dextrose in TPN increases the risk of hyperglycemia until the pancreas begins to produce more insulin or exogenous insulin is administered. TPN increases the likelihood of hyperphosphatemia and hyperkalemia, so electrolytes should be monitored. Hypouricemia is seen commonly after several days of total parenteral nutrition. Solutions rich in dextrose may increase urate excretion due to an osmotic effect.

An older adult client has been prescribed zolpidem for insomnia. The nurse should monitor the client for which side/adverse effect of this medication? Tachypnea Hypotension Tachycardia Constipation

Hypotension Rationale: Zolpidem is classified as a non-benzodiazepine and acts as a GABA agonist which can cause central nervous system depression, including drowsiness and lightheadedness. Nurses should be aware of the sedative effects and assess for hypotension, bradycardia, and bradypnea. Diarrhea, not constipation, is more commonly associated with the administration of this medication.

The nurse is educating a client on self-administration of a fluticasone inhaler. What statement indicates an understanding of the teaching? I will rinse my mouth with water after using the inhaler." "Disinfectant wipes can be used to clean the spacer." "I need to wait 15 minutes between puffs." "This inhaler should be used before the others."

I will rinse my mouth with water after using the inhaler." Rationale: To prevent thrush, the client should rinse his or her mouth with water and spit it out. The spacer should be washed with warm water and dish detergent. The client may need two puffs but does not have to wait 15 minutes between. Bronchodilators should be used before corticosteroids.

The nurse is providing education to the client prescribed montelukast for the treatment of asthma. What medication should the nurse instruct the client to avoid? Ibuprofen Prednisone Amoxicillin Formoterol

Ibuprofen Rationale: Montelukast should not be taken with NSAIDs. It increases the risk of bleeding as well as has the potential to make asthma symptoms worse. Prednisone, amoxicillin, and formoterol are all safe to administer to the client on montelukast.

A nurse is providing care to a client with ovarian cancer prescribed intravenous topotecan. The nurse expects to administer the medication via which venous access site? Implanted port PICC Central line Peripheral

Implanted port Rationale: Topotecan is an antineoplastic medication administered over the course of 21 days. Chemotherapy medications are commonly administered via an implanted port. An implanted port is accessed through the skin only when therapy is needed. A peripherally inserted central line (PICC), a central line, and a peripheral line have continuous external access and have a higher risk of infection.

A nurse is preparing to administer doxorubicin to a client with bladder carcinoma. How will the nurse prepare this medication? While wearing sterile gloves In a biological safety cabinet Inside a temperature-controlled room By withdrawing into a syringe undiluted

In a biological safety cabinet Rationale: Doxorubicin should be prepared in a biological safety cabinet. Doxorubicin is a high-risk medication whose fumes may cause health hazards. A biosafety cabinet controls the airflow while preparing this medication. Sterile gloves are not required. Standard gloves, a gown, and a mask should be worn when preparing this medication. The temperature of the room is not a specified guideline for preparing this medication. Doxorubicin should be diluted with normal saline before administration.

The nurse is preparing to administer eye drops to a 6-year-old child. Which of the following is the correct method the nurse should use when instilling eye drops to the client? A In the corner where the lids meet B On the anterior surface of the eyeball C Under the upper lid as it is pulled upward D In the conjunctival sac as the lower lid is pulled down

In the conjunctival sac as the lower lid is pulled down Rationale: When administering eye drops, the nurse should position the client either sitting or lying down with the head supported. They should wash their hands before instilling eye drops to prevent cross infection. Before administration, they should establish that they have the correct eye drops and that they have not expired. The nurse should agitate the bottle before use to make sure the drug is properly mixed. The nurse should instill the eye drops into the space created by gently pulling down the lower lid. The client should look up to make sure the eye drops do not land directly onto the sensitive cornea. Once the eye drops are instilled, the nurse should release the eyelid, and use a tissue or swab to dab any excess from the cheek.

A nurse is providing care to a client in cardiogenic shock. The client is on a prescribed dopamine infusion at 10 mcg/kg/min with orders to titrate as needed. The latest blood pressure is 75/40 mmHg. Which action does the nurse perform next? Recheck the client's blood pressure Increase the infusion rate to 12 mcg/kg/min Report the findings to the healthcare provider Decrease the infusion rate to 8 mcg/kg/min

Increase the infusion rate to 12 mcg/kg/min Rationale: The nurse should increase the dose of dopamine. The therapeutic goal of dopamine is to increase blood pressure and improve cardiac output. A blood pressure of 75/40 mmHg indicates the current rate is not effective. Rechecking the client's blood pressure is not necessary. The client is in cardiogenic shock and hypotension is an expected finding. The nurse can recheck the blood pressure after titrating the dose. Reporting the findings to the healthcare provider is important. However, the nurse should first titrate the dose to ensure the client's blood pressure is maintained. Decreasing the infusion rate will cause further hypotension.

The nurse is caring for a client who received digoxin-specific immune fab. Which finding indicates the treatment is having the intended effect? Increased heart rate Decreased potassium levels Decreased blood pressure Increased serum digoxin levels

Increased heart rate Rationale: Digoxin-specific immune fab is an antidote that binds molecules of digoxin, making them unavailable for binding at their usual sites of action in the body. After administration of the medication, serum digoxin levels may be misleading, as they will be elevated until the drug is excreted by the kidneys. The goal of treatment is to lower digoxin levels and treat symptomatic digoxin toxicity, specifically cardiac dysrhythmias including bradycardia. Potassium levels may be low, triggering digoxin toxicity, and then elevated due to shifts caused by digoxin toxicity, so fluctuating levels are not a sign of effective treatment. Effective treatment of dysrhythmia should raise blood pressure.

The nurse is teaching a client about newly prescribed inhaled budesonide. The nurse should teach the client to report which finding to the healthcare provider? Rounded face Bradycardia Increased thirst Cough

Increased thirst Rationale: Respiratory disorders, such as asthma, status asthmatic, chronic obstructive pulmonary disease (COPD), and rhinitis, may all be treated with corticosteroids, including budesonide. Corticosteroids have many common side effects including cushingoid features, such as "moon face" due to redistribution of fat. Fluid retention is also common when using corticosteroids. Increased thirst may be an indication of hyperglycemia and should be reported. Corticosteroids can increase heart rate. A cough is normal with corticosteroids as the airway is dilated.

A nurse is assessing a client on continuous IV therapy. The client's IV access site is cool to the touch, and the dressing feels moist. Which action should the nurse take? Discontinue the intravenous infusion Initiate IV access in a different site Apply a new dressing to the access site Place a warm compress on the client's extremity

Initiate IV access in a different site Rationale: The nurse should initiate IV access in a different site. The signs at the current access site are indicative of infiltration. Continuous intravenous therapy should not be discontinued without a healthcare provider's prescription. Applying a new dressing and placing a warm compress does not address the issue of possible infiltration. The intravenous catheter should be removed, and access should be initiated in a different site.

A nurse receives a prescription to administer intravenous cefepime to a client with a bacterial infection. The client has a history of lung cancer and is on a continuous cisplatin infusion. How will the nurse administer the prescribed medication? Piggyback the cefepime onto the cisplatin infusion Wait for the cisplatin infusion to finish before administering cefepime Infuse the cefepime via IV push at the proximal port Initiate a new intravenous line for the cefepime infusion

Initiate a new intravenous line for the cefepime infusion Rationale: Cefepime is an antibiotic medication used to treat bacterial infections. Cisplatin is an antineoplastic medication used in the treatment of various cancers. Cefepime and cisplatin are not compatible and should not be mixed. The nurse should initiate a new intravenous line for the administration of cefepime. Piggybacking the cefepime will cause the medication to mix with cisplatin. The medications are not compatible. A continuous cisplatin infusion is administered over 24 hours to 5 days. The nurse should not wait to administer other medications. Cefepime should be administered as an infusion, not an IV push.

The nurse is caring for a client with a paralytic ileus who is receiving total parenteral nutrition (TPN). The client has developed hypernatremia and is confused. Which of the following prescriptions would the nurse anticipate? Initiating a 5% dextrose infusion Encouraging oral intake of plain water Giving a furosemide injection Modifying the sodium in the subsequent TPN infusion

Initiating a 5% dextrose infusion Rationale: Abnormalities of serum electrolytes and minerals should be corrected by modifying subsequent infusions or, if correction is urgently required, by beginning appropriate peripheral vein infusions. Elevated blood urea nitrogen and hypernatremia may reflect dehydration, which can be corrected by giving free water as 5% dextrose or hypotonic saline via a peripheral vein. The client is NPO, so oral intake is contraindicated. Furosemide will worsen hypernatremia.

The nurse is preparing to administer a client's prescribed NPH and regular insulins. Which action should the nurse take first when mixing the insulins in one syringe? Draw up the NPH Draw up the regular insulin Inject air into the NPH Inject air into the regular insulin

Inject air into the NPH Rationale: When mixing insulins in the same vial, the process should be to inject air into the long-acting insulin, inject air into the short-acting insulin, draw up the short-acting insulin, and then draw up the long-acting insulin.

The nurse is preparing to administer a client's prescribed insulins and needs to mix NPH and lispro. Which of the following actions should the nurse take first? Inject air into the long-acting insulin Draw up the short-acting insulin Draw up the long-acting insulin Inject air into the short-acting insulin

Inject air into the long-acting insulin Rationale: When mixing insulins in the same vial, the process should be to inject air into the long-acting insulin, inject air into the short-acting insulin, draw up the short-acting insulin, and then draw up the long-acting insulin.

A client is admitted with a tentative diagnosis of left-sided heart failure. Which assessment finding is consistent with this diagnosis? A Cyanosis B Heart murmur C Chest pain D Inspiratory crackles

Inspiratory crackles Rationale: Signs and symptoms of HF are related to the ventricle most affected. Left-sided heart failure affects the left ventricular function. Crackles that do not clear with coughing are an early sign of left-sided heart failure. As pulmonary congestion increases, crackles become more pronounced. Oxygen saturation may decrease at this time.

The nurse is providing teaching to the client taking metoclopramide. Serious side effects that should be reported to the provider are included in the teaching plan. Which of the following side effects is the priority? Involuntary muscle movements Report of increased fatigue Onset of headaches Difficulty with sleep

Involuntary muscle movements Rationale: Metoclopramide is a GI stimulant that is effective in reducing headache, nausea, and vomiting. Metoclopramide can cause a serious movement disorder called tardive dyskinesia (TD). This condition is often irreversible. TD is characterized by involuntary movements of the face, tongue, or extremities. The risk of developing TD is increased with longer treatment and increased dosage. To help prevent TD, this drug shouldn't be used for longer than 12 weeks. The more common side effects of metoclopramide can include headache, confusion, drowsiness, dizziness, restlessness, and insomnia.

The oncology nurse is caring for a female client who is being treated for metastatic breast cancer. The client is scheduled to receive their first dose of trastuzumab. Which assessment finding is most important to notify the health care provider of? A Blood glucose 130 mg/dL B Absolute neutrophil count 2.5 (2,500 mm3) C Intermittent nausea and vomiting D Irregular apical pulse

Irregular apical pulse Rationale: Trastuzumab is a monoclonal antibody used as anticancer therapy for women with HER2-positive breast cancer. The main concern in administering trastuzumab is cardiotoxicity, manifesting as ventricular dysfunction and congestive heart failure. Therefore, the irregular apical pulse is the most important assessment findings. An ejection fraction is obtained as a baseline before treatment and may be monitored every few months while the client is receiving this medication. The other findings are to be expected, normal or near normal and not as important as the irregular apical pulse.

The nurse is providing discharge instructions to an older adult client with heart failure. The client asks, "What is the purpose for taking the furosemide?" How should the nurse respond? A It will protect your kidneys from chronic damage. B It will reverse the damage to your heart muscle. C It will help with reducing the risk for an irregular heart rhythm. D It will help with decreasing fluid buildup in your lungs.

It will help with decreasing fluid buildup in your lungs. Rationale: Furosemide is a loop diuretic. Diuretics are the first-line drug of choice in older adults with heart failure (HF) and fluid overload. These drugs enhance the renal excretion of sodium and water by reducing circulating blood volume, decreasing preload, and reducing systemic and pulmonary congestion, i.e., decreased fluid buildup in the lungs. The other actions do not pertain to furosemide.

The nurse is educating an older adult client about newly prescribed levofloxacin for the treatment of pneumonia. The nurse should teach the client that which side effect is a priority for the client to report to the provider? Joint tenderness Diarrhea Dizziness Difficulty sleeping

Joint tenderness Rationale: There is a black box warning for fluoroquinolones alerting health professionals not only to the increased disabling risk of tendinitis and tendon rupture but also to the significant risk of peripheral neuropathy, central nervous system and cardiac effects, and dermatologic and hypersensitivity reactions. Signs of tendonitis and tendon rupture include pain and tenderness in the affected limb or joint. The medication must be stopped immediately. The other options are common side effects and while reportable, are not a priority.

A client with advanced liver disease has been taking rifaximin. Which assessment finding would indicate that the medication is being effective? A Less jaundice B Increased appetite C Less edema D Less confusion

Less confusion Rationale: Clients with advanced liver disease experience elevated serum ammonia levels, which typically lead to hepatic encephalopathy. Signs and symptoms of hepatic encephalopathy include personality changes, confusion, restlessness, and forgetfulness. Rifaximin is an antibiotic that helps reduce ammonia levels and hepatic encephalopathy by stopping the growth of bacteria and the production of ammonia in the GI tract. Lessening confusion would indicate that the medication is being effective.

A nurse is providing care to a client diagnosed with a myocardial infarction. The client has a history of hypothyroidism and hypertension. Which prescribed medication will the nurse clarify before administering it to the client? Morphine Levothyroxine Aspirin Labetalol

Levothyroxine Rationale: Levothyroxine is a synthetic thyroid hormone used in the treatment of hypothyroidism. Levothyroxine can induce cardiac stimulant effects and is contraindicated in clients with a recent myocardial infarction (MI). Morphine and aspirin are commonly administered after a cardiac event. Morphine relieves pain associated with cardiac ischemia and aspirin decreases platelet aggregation that leads to blood clotting. Labetalol is a beta-blocker used in the treatment of hypertension. There is no known contraindication for the use of labetalol after an MI.

A nurse is providing care to a female client who is 32-weeks pregnant. The client has been diagnosed with hypertension and will begin prescribed pharmacological treatment. The nurse will clarify which medication if observed in the client's record? Spironolactone Methyldopa Lisinopril Hydralazine

Lisinopril Rationale: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used in the treatment of hypertension. ACE inhibitors are pregnancy risk category D and are contraindicated during the second and third trimesters of pregnancy. Spironolactone and methyldopa are pregnancy risk category B and have been used routinely and safely during pregnancy. Hydralazine is a pregnancy risk category C, but its use has been proven to be safe during pregnancy.

The nurse is caring for a client with diabetes mellitus. The client reports feeling hungry and thirsty. The client's most recent blood glucose level was 175 mg/dL. Which type of insulin should the nurse anticipate being prescribed for this client? A Exenatide B Glucagon C Sitagliptin D Lispro

Lispro Rationale: The inpatient client with an elevated blood sugar is usually prescribed a short-acting insulin such as lispro, aspart or regular (Humulin-R) insulin. Glucagon is a medication used to treat hypoglycemia, not hyperglycemia. Exenatide and sitagliptin are not insulins.

A client with diabetes is starting on insulin therapy. Which type of short-acting insulin will the nurse discuss using for mealtime coverage? A Detemir B NPH C Glargine D Lispro

Lispro Rationale: When classified according to time course, insulin preparations fall into three major groups: short duration, intermediate duration and long duration. Lispro is a rapid-acting insulin with an onset of 15 to 30 minutes, a peak of 0.5 to 2.5 hours and duration of 3 to 6 hours. Rapid- or short-acting insulin is commonly used for mealtime coverage for clients receiving insulin therapy. NPH insulin, glargine or detemir will be used as the basal insulin for intermediate- and long-duration blood sugar control.

The nurse is assessing the client's ability to perform proper use of a cane while ambulating. Which of the following actions by the client requires intervention? Stepping with the weaker leg after moving the cane Holding the cane on the client's stronger side of the body Looking down at the cane while moving the legs forward Maintaining the top of the cane at the level of the hip

Looking down at the cane while moving the legs forward Rationale: It indicates proper use of a cane to move the cane first, followed by the weaker leg, and then the stronger leg, which provides a constant wide base of support. The client should hold the cane on the stronger side of the body and maintain the cane at the level of the hip. Clients should be instructed to stand up straight and look forward, not down at the cane, to reduce the risk of falling.

The nurse is caring for a client prescribed furosemide and digoxin for the treatment of heart failure. The client reports seeing halos and bright lights. Which laboratory result would be anticipated? Low sodium level Low digitalis level Low potassium level Low serum osmolality

Low potassium level Rationale: Digitalis toxicity is an accumulation of digitalis (digoxin) in the body that leads to nausea, vomiting, visual disturbances, atrial or ventricular tachydysrhythmias, ventricular fibrillation, sinoatrial block, and atrioventricular block. Clients with heart failure who take digoxin are commonly given diuretics. Hypokalemia can increase the risk of digitalis toxicity. Digitalis toxicity may also develop in the presence of hypomagnesemia. Clients with dig toxicity would have elevated digoxin levels. Sodium would likely be normal. The serum osmolality would likely be normal or high in a client on a diuretic.

A nurse is reviewing prescriptions for a client with a deep vein thrombosis to the right lower extremity (RLE). Which prescription should the nurse clarify? Apply graduated compression stocking to the RLE Massage the RLE as needed Perform range of motion exercises to the RLE Elevate the RLE above the level of the heart

Massage the RLE as needed Rationale: A deep vein thrombosis is a blood clot that forms within a vein and obstructs blood flow. The goal of treatment is to increase circulation to the extremity once anticoagulant therapy is initiated. Massaging the affected extremity is contraindicated, as it can dislodge the blood clot and cause obstruction of other vessels. Applying graduated compression stockings is an expected treatment. Compression stockings increase the velocity of blood flow and improve valve function in the veins. Range of motion exercises are encouraged and improve muscle tone and circulation to the extremity. Elevating the affected extremity above the level of the heart increases venous blood flow.

The nurse is planning care for a pediatric client with a new prescription for adenosine to treat symptomatic supraventricular tachycardia (SVT). Which action should the nurse include in the plan of care? Monitor for ventricular dysrhythmias Monitor for shortness of breath Monitor for hypertension Monitor for nausea.

Monitor for shortness of breath Rationale: After giving adenosine, the nurse would monitor for shortness of breath, dyspnea, and a worsening of asthma, as they are expected effects/outcomes with this medication. Monitoring for ventricular dysrhythmias is necessary when giving dobutamine, dopamine, and epinephrine but not adenosine. Vomiting is not an expected outcome of adenosine. The nurse should include monitoring for hypotension, not hypertension, in the plan of care after administration of adenosine and instruct parents to change positions slowly to minimize orthostatic hypotension.

The nurse is caring for a client with an inner ear infection who is experiencing vertigo. Which intervention would protect the client from injury? Monitor the client for falls Document vital signs Speak to the client on the unaffected side Provide medication for nausea

Monitor the client for falls Rationale: Some clients may experience vertigo, a sensation of spinning, with inner ear infections. Clients with vertigo will report feeling dizzy, which could lead to falls and cause injury. Monitoring for falls will protect the client from injury. Vertigo can also cause nausea and is treated with medication but does not cause injury. Clients may also have hearing loss, which is not an injury, related to vertigo, so speaking to the client on the unaffected side will make sure the client understands the instructions. Documenting vital signs will allow assessing of trends with vertigo but will not prevent injury.

The nurse is preparing to start a blood transfusion for a client with severe anemia. To reduce the risk of adverse transfusion reactions, which interventions are essential to include? Select all that apply. Administration of supplemental oxygen Monitoring of vital signs before, during and after the transfusion Maintaining the client on complete bed rest during the transfusion Use and priming of the appropriate tubing for the prescribed blood component Verification of client by name, blood band number, blood type compatibility Placement of an appropriate size venous access device

Monitoring of vital signs before, during and after the transfusion Use and priming of the appropriate tubing for the prescribed blood component Verification of client by name, blood band number, blood type compatibility Placement of an appropriate size venous access device Rationale: Nursing actions during blood transfusions focus on prevention or early recognition of adverse transfusion reactions. Preparation of the client for transfusion is critical, and blood product administration procedures must be followed carefully. Human error is the most common cause of ABO incompatibility reactions. A peripheral venous access device should preferably be at least 20-gauge size. Client and blood product verification must be done by two [registered] nurses at the client's bedside. Vital signs should be obtained immediately prior to starting the transfusion, 15 and 30 minutes after start of the transfusion and hourly during the transfusion. Supplemental oxygen and bed rest are generally not required during a blood transfusion and will not prevent adverse transfusion reactions.

The nurse is preparing to administer metoprolol to a client with a history of hypertension. Which of the following data is the priority for the nurse to review prior to administration? Potassium level Most recent heart rate Creatinine level Respiratory rate

Most recent heart rate Rationale: Beta-blockers, such as metoprolol, can decrease heart rate and blood pressure, so the nurse should review these specific vital signs prior to administering the medication. Most prescriptions will state to hold the medication if the heart rate or blood pressure is less than a designated value. Potassium and creatinine levels are monitored with clients who are taking lisinopril, an ACE inhibitor. Respiratory rate is an important part of assessment but is not the priority for the administration of a beta-blocker.

The nurse is educating a client about newly prescribed chlorpromazine. Which of the following should the nurse include in the teaching as an adverse effect of the medication? Photosensitivity Muscle rigidity Weight gain Dry mouth

Muscle rigidity Rationale: Muscle rigidity may indicate neuroleptic malignant syndrome (NMS) and should be reported to the health care provider immediately. Weight gain has been associated with first-generation (conventional) antipsychotics. Photosensitivity is a common side effect associated with chlorpromazine. Anticholinergic effects (e.g., dry mouth, hypotension, and urinary retention) are also common side effects with this medication and should be monitored but do not require immediate intervention.

A nurse is providing care to a client post-cholecystectomy. Which observation indicates the client may require PRN pain medication? Slow gait when ambulating to the restroom Guarding when the abdomen is palpated Muscle tension when repositioning in bed Refusal to eat the provided meals

Muscle tension when repositioning in bed Rationale: Pain is an expected response for a postoperative client. The nurse should assess behaviors that prevent activities of daily living (ADLs) due to pain. Sustained muscle tension can prevent the client from performing ADLs. A slow gait is a protective response to movement after a surgical procedure. Palpation around the surgical area will produce an expected pain response. A refusal to eat is not specific to pain. It may be due to other factors, such as nausea.

The nurse is providing care for a client admitted to the hospital with a diagnosis of digoxin toxicity. The client reports more than usual urine output over the previous 48 hours, because of the prescribed diuretic. Which assessment finding does the nurse anticipate? A Blood in the urine B Tinnitus C Hypertension D Muscle weakness or cramping

Muscle weakness or cramping Rationale: The client with heart failure on digoxin and a diuretic is at risk for hypokalemia. The digoxin binds to the potassium receptor of the sodium/potassium ATPase pump. The increased urine output makes hypokalemia likely and thus it is more likely for digoxin toxicity to occur. Symptoms of hypokalemia include muscle weakness and cramping. The digoxin toxicity will not cause blood in the urine, or tinnitus or hypertension.

The nurse is reviewing medication instructions with a client who is taking digoxin. The nurse should reinforce to the client to report which of the following side effects? A Rash, dyspnea, edema B Polyuria, thirst, dry skin C Hunger, dizziness, diaphoresis D Nausea, vomiting, fatigue

Nausea, vomiting, fatigue Rationale: Digoxin is considered an antidysrhythmic and inotrope, that is used to treat atrial dysrhythmias and congestive heart failure. The medication produces a positive inotropic effect, prolongs the refractory period and slows conduction through the sinoatrial (SA) and atrioventricular (AV) nodes. Overall, digoxin increases cardiac output and slows the heart rate. The effects of digoxin produce many side effects and clients who take digoxin are at risk for digoxin toxicity. Because digoxin improves cardiac output, side effects of the medication would not include dyspnea or edema. Rashes are also not considered a side effect of digoxin. Common manifestations of digoxin toxicity include nausea, vomiting and fatigue. Hunger, dizziness and diaphoresis, together, are not considered side effects of digoxin. Although dizziness could occur with another side effect of digoxin, such as bradycardia. Polyuria, thirst and dry skin are not considered side effects of digoxin.

A nurse is reviewing laboratory data of a client taking paclitaxel for ovarian cancer. Which finding would the nurse report to the healthcare provider before administering the next dose of medication? Platelet count of 475,000/mm³ Eosinophil level of 400/mm³ Red blood cell count of 6.5 million/mm³ Neutrophil count of 1,200/mm³

Neutrophil count of 1,200/mm³ Rationale: Paclitaxel is an antineoplastic medication used in the treatment of various cancers. Paclitaxel causes neutropenia and is contraindicated in clients with a neutrophil count below 1,500/mm³. A platelet count of 475,000/mm³ is above normal. Paclitaxel can cause thrombocytopenia (low platelet count). Eosinophils are white blood cells that fight infectious organisms. An eosinophil level of 400/mm³ is a normal finding. A red blood cell (RBC) count of 6.5 million/mm³ is above normal. Paclitaxel can cause anemia (low RBCs).

he nurse is caring for a pregnant client who is receiving intravenous magnesium sulfate therapy. Which of the following medication prescriptions should the nurse clarify with the provider? Nifedipine Ondansetron Lactated ringers Betamethasone

Nifedipine Rationale: The effect of the calcium channel blocker can be increased if it is taken with magnesium sulfate; therefore, the nurse should question a new prescription of nifedipine. All other medications will not create adverse effects if given with magnesium sulfate.

The nurse is assessing a client who is taking prescribed opioids for pain. Which finding should indicate to the nurse that the client is having a side effect of the medication? Decreased skin turgor No bowel movement for four days Hypertension Increased respiratory effort

No bowel movement for four days Rationale: A side effect is a mild, predictable response to a medication. Opioids slow down processes in the body, including gastrointestinal motility, so a possible side effect of this medication would be constipation. Skin turgor is not directly affected by opioids. A client who is having side effects of opioids will have hypotension and decreased respiratory effort.

The nurse is completing a client's medication reconciliation. The nurse notes a discrepancy between the current prescribed medications and the client's home medications. Which action by the nurse is most appropriate? Document the discrepancy in the medical record Discontinue the prescription that was incorrect Notify the provider about the discrepancy Complete an incident report

Notify the provider about the discrepancy Rationale: The purpose of a medication reconciliation is to identify and prevent prescription duplications, omissions, errors, and potential interactions between the currently prescribed medications and those that the client is taking regularly. If an issue is identified, the nurse should notify the provider to determine if the current medication has been prescribed correctly or if the order needs to be modified. Discontinuing the prescription is out of the nurse's scope of practice. Documenting in the medical record may be necessary but is not the most appropriate action. An incident report is not needed unless a medication error occurred.

The client is newly diagnosed with type 1 diabetes mellitus. Which of these approaches would be the best strategy for the nurse to use when teaching insulin injection techniques? A Ask questions during practice B Give written pre and post tests C Allow another diabetic to assist D Observe a return demonstration

Observe a return demonstration Rationale: Learning to inject oneself is a challenging task and the nurse should first demonstrate the injection and then ask for a return demonstration from the client. Giving a written test is not appropriate for this teaching. Asking questions during practice is important, but the nurse still needs to see the client self-inject. Asking another diabetic to assist is not appropriate

The nurse is caring for a client who is experiencing excessive bleeding after receiving unfractionated heparin sodium. Which orders should the nurse anticipate from the health care provider? Select all that apply. Obtain activated partial thromboplastin time (aPTT). Administer vitamin K. Obtain prothrombin time (PT)/international normalized ratio (INR). Change prescription to enoxaparin. Administer protamine sulfate.

Obtain activated partial thromboplastin time (aPTT). Administer protamine sulfate. Rationale: Protamine sulfate is the antidote used to reverse the anticoagulant effects of heparin. A serum aPTT or PTT lab test is used to evaluate the anticoagulation effect of heparin. Vitamin K is the antidote for warfarin. A serum PT/INR lab test is used to monitor the therapeutic effectiveness of warfarin. Enoxaparin is another type of heparin and would be contraindicated for this client.

The client is using nonsteroidal anti-inflammatory drugs (NSAIDs) to manage arthritis pain. The nurse should caution the client about which potential side effect? A Constipation B Nystagmus C Urinary incontinence D Occult bleeding

Occult bleeding Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) taken for long periods of time may cause serious side effects including bleeding in the gastrointestinal tract. Clients should be instructed to take the medication with meals if stomach upset occurs. To avoid esophageal irritation, the client should take the drug with a full glass of water and avoid lying down for 30 to 60 minutes after taking a dose.

The nurse works in an assisted living facility and cares for older adults. The nurse understands that older adults are at a greater risk for drug toxicity than younger adults due to which physiological change associated with aging? A Drugs are absorbed more readily from the gastrointestinal tract. B Older adults have a more rapid hepatic metabolism. C Older adults are often malnourished and anemic. D Older adults have less body water and more fat.

Older adults have less body water and more fat. Rationale: Because older adults have decreased lean body tissue and water in which to distribute medications, more drug remains in the circulatory system creating a potential for drug toxicity. Increased body fat results in greater amounts of fat-soluble drugs being absorbed, leaving less medication in circulation and thus increasing the duration of action of the drug.

A nurse has administered sublingual nitroglycerin to a client in the emergency department. Which clinical finding indicates an adverse response to the medication? Persistent chest pain Orthostatic hypotension Decreased heart rate Labored breathing

Orthostatic hypotension Rationale: Decreased blood pressure when changing positions is an unexpected response to nitroglycerin. The nurse should instruct the client to lay down and elevate the feet to promote venous return. Persistent chest pain is not an unexpected response. Additional doses may be required to alleviate angina. A side effect of nitroglycerin is tachycardia, not a decreased heart rate. Nitroglycerin is not associated with respiratory effects.

The nurse is providing teaching to the client prescribed albuterol for the management of asthma. The nurse is including reportable side effects in the teaching plan. Which of the following side effects is the priority? Nervousness Headache Palpitations Muscle aches

Palpitations Rationale: Side effects of albuterol include nervousness, shakiness, headache, throat irritation, and muscle aches. Muscle tremor is the most frequent adverse effect. The main risks with adrenergic bronchodilators, particularly in older adults, are excessive cardiac and central nervous system (CNS) stimulation. Symptoms of cardiac stimulation include angina, tachycardia, and palpitations. Symptoms of central nervous system (CNS) stimulation consist of agitation, anxiety, insomnia, seizures, and tremors. Other reported effects may include serious dysrhythmias and cardiac arrest.

The nurse is educating a client prescribed metronidazole. Which of the following findings should the nurse include in the education as reportable to the healthcare provider? Pinpoint red spots on the skin Nausea after beginning the medication Metallic taste Occasional diarrhea

Pinpoint red spots on the skin Rationale: The most common gastrointestinal effects of metronidazole are nausea, vomiting, diarrhea, and metallic taste. Drug-induced immune thrombocytopenia (DITP) is a rare, but serious, adverse effect where medications cause the body to produce antibodies to platelets. The medication must be stopped immediately because DITP can be life-threatening. Heparin-induced thrombocytopenia is one example. Metronidazole is associated with DITP. Petechiae are pinpoint, round spots that appear on the skin as a result of bleeding. The bleeding causes the petechiae to appear red, brown, or purple.

A nurse is caring a client who was admitted for diarrhea and has been diagnosed with a Clostridium difficile infection (CDI). To reduce the risk of transmission, which action should the nurse take? Perform frequent hand hygiene with alcohol- based hand sanitizer Clean shared equipment with standard disinfecting wipes Move the client to a negative pressure room Place dirty linens directly into the soiled linen cart

Place dirty linens directly into the soiled linen cart Rationale: C. diff is a spore-forming, gram-positive anaerobic bacillus. It is a common cause of antibiotic-associated diarrhea (AAD). C. diff is shed in feces so any surface, device, or material that becomes contaminated with feces could serve as a reservoir. C. diff spores can also be transferred to patients via the hands of healthcare personnel who have touched a contaminated surface or item. Use contact precautions for patients with CDI. Because alcohol does not kill C. diff spores, the use of soap and water is more effective than alcohol-based hand hygiene. Bleach-based wipes should be used for cleaning surfaces and shared equipment. The linens of a client with C. diff diarrhea may be contaminated and should be immediately placed in the soiled linen cart. Do not lay dirty linens on any surface.

The nurse is preparing to administer a subcutaneous injection to a client. Which of the following locations would be an appropriate administration site? Posterior surface of the upper arm Anterior to the sternum Dorsal surface of the hand Medial aspect of the lower leg

Posterior surface of the upper arm Rationale: Appropriate subcutaneous injection sites have a higher proportion of adipose tissue, and common sites include the posterior surface of the upper arm, the abdomen, and the anterior surface of the thigh. The sternum, dorsal surface of the hand, and medial aspect of the lower leg do not have significant adipose tissue present.

A nurse is reviewing laboratory data for a client taking pramlintide for diabetes management. Which clinical finding indicates medication effectiveness? Postprandial glucose of 160 mg/dL Hemoglobin A1c of 8.5% Fasting blood glucose of 135 mg/dL Preprandial glucose of 150 mg/dL

Postprandial glucose of 160 mg/dL Rationale: Pramlintide is an antidiabetic medication used in the treatment of diabetes mellitus in conjunction with other hypoglycemic drugs. The therapeutic goal of pramlintide is to achieve postprandial glucose levels below 180 mg/dL. A preprandial blood glucose of 150 mg/dL, a hemoglobin A1c of 8.5%, and a fasting blood glucose of 135 mg/dL are all indicative of poor disease management. The goal is a preprandial glucose level of less than 130 mg/dL, a hemoglobin A1c level of less than 7%, and a fasting blood glucose of less than 100 mg/dL.

The nurse is preparing to administer doxycycline to a client to treat syphilis. Which lab results should the nurse review before administering this medication? Pregnancy test Hematocrit Sodium level Arterial blood gas

Pregnancy test Rationale: Tetracyclines, such as doxycycline, may cause fetal harm and should not be administered during pregnancy. It is important to know the client's pregnancy status prior to administration. Reviewing hematocrit, serum sodium level, and ABGs may be a part of the client's assessment, but these do not affect the prescription for doxycycline.

The nurse is caring for a client with a new prescription for a selective serotonin reuptake inhibitor (SRRI) to treat depression. In reviewing the admission history and physical, which finding should the nurse clarify with the health care provider? A History of morbid obesity B Diagnosis of peripheral vascular disease C Reported frequent use of antacids D Prescribed monoamine oxidase (MAO) inhibitor

Prescribed monoamine oxidase (MAO) inhibitor Rationale: Selective serotonin reuptake inhibitors (SSRIs) are indicated for treatment of depression, panic attacks, bulimia, social phobias and social anxiety disorders. The medication blocks the uptake of serotonin and increases its level in the synaptic cleft. Examples of SSRIs include fluoxetine, sertraline and escitalopram. Clients should not take monamine oxidase inhibitors (MAOIs) concurrently with SSRIs because serious, life-threatening reactions (i.e., serotonin syndrome) may occur with this combination of drugs. The nurse should notify the provider about this finding. The other findings do not represent a contraindication for taking SSRIs.

The nurse is admitting a client to the hospital with findings of liver failure and ascites. A health care provider (HCP) orders spironolactone. The nurse understands that the pharmacological effects of the medication, are which of the following? A Increases aldosterone levels B Combines safely with antihypertensives C Depletes potassium reserves D Promotes sodium and chloride excretion

Promotes sodium and chloride excretion Rationale: Spironolactone is considered a diuretic that is indicated for individuals with hypertension, edema, congestive heart failure and potassium loss. Spironolactone promotes sodium and chloride excretion while sparing potassium and decreasing aldosterone levels. Spironolactone is often combined with other diuretics and anti-hypertensive agents. Kidney function and electrolytes should be monitored more closely when spironolactone is used in combination with other medications. The medication is considered a potassium-sparing diuretic, because as aldosterone levels decrease and sodium and water is excreted, potassium is spared. A major side effect of spironolactone is hyperkalemia.

The nurse is caring for a client who is receiving a continuous intravenous heparin infusion. The client's most recent activated partial thromboplastin time (aPTT) is 120 seconds. Which medication should the nurse plan to administer? Protamine Naloxone Enoxaparin Vitamin K

Protamine Rationale: The client's aPTT is much higher than the typical desired therapeutic range of 1.5-2.5 the control value and places the client at great risk for uncontrolled bleeding. Protamine sulfate is the medication used to reverse the effects of heparin; it is a heparin antagonist. Neutralization of heparin occurs immediately and lasts for 2 hours, after which additional protamine may be needed. Protamine is administered by slow IV injection (no faster than 20 mg/ min or 50 mg in 10 minutes). Dosage is based on the fact that 1 mg of protamine will inactivate approx. 100 units of heparin. Vitamin K is used to reverse the effects of warfarin. Naloxone is used to reverse the effects of opioids. Enoxaparin is another anticoagulant (low molecular weight heparin).

The nurse is assessing a client who is receiving antibiotic therapy for an infection. Which finding should indicate to the nurse that the client may be experiencing an allergic reaction to a medication? Xerostomia Hypertension Pruritus Lymphadenopathy

Pruritus Rationale: If the client experiences pruritus, the nurse should be concerned about the possibility of an allergic reaction. Xerostomia, or dry mouth, and lymphadenopathy are not signs of a hypersensitivity reaction. A client experiencing an allergic reaction will experience hypotension.

A nurse is preparing to move a client up in bed. The client is unable to assist in repositioning and assistance is obtained. Which action demonstrates use of ergonomic principles? Twist at the waist while lifting the client Raise the bed to the nurse's working height Keep the feet close together Lift and move in an uncoordinated fashion

Raise the bed to the nurse's working height Rationale: Twisting at the waist, keeping the feet close together when lifting and moving, and performing uncoordinated lifting and moving all increase the risk of back injuries in nurses. Raising the bed height reduces lower back strain.

The nurse has a prescription to administer dopamine 2 mcg/kg/min for a client who weighs 110 lbs. The supply available is 200 mg in 250 ml normal saline. How many ml/hr will the client receive? Round answer to the nearest tenth.

Rationale: 110 lbs / 2.2 = 50 kg; 50 kg x 2 mcg/min = 100 mcg/min; ml/hr = (250 ml / 200 mg) x (1 mg / 1,000 mcg) x (100 mcg/min) x (60 min/hr) = 7.5

The nurse is caring for a client who weighs 188 lbs. The nurse received a prescription for the client to receive methylprednisolone 2 mg/kg. The label reads 125 mg / 2 ml. How many ml should the nurse administer to the client with each dose? Round answer to the nearest tenth.

Rationale: 188 lbs / 2.2 = 84.45 kg; 84.45 kg x 2 mg = 168.9 mg; ml/dose = (2 ml / 125 mg) x (168.9 mg/dose) = 337.8 / 125 = 2.7024 = 2.7

The nurse is preparing to administer acetaminophen 7.5 mg/kg PO to a pediatric client. The client weighs 20 kg. How many milligrams per dose should the nurse administer to the client?

Rationale: 7.5 mg x 20 kg = 150

The nurse is teaching a client with cardiac disease who is taking furosemide and digoxin about foods rich in potassium. Which food choice best indicates the client understands the teaching? A A baked potato Correct Answer (Blank) B An apricot C A small orange D A small banana

Rationale: A baked potato contains approximately 610 mg of potassium. Apricots, oranges and bananas are also sources of potassium, but because of their size, they are not the highest in potassium. A baked potato is the highest in potassium of the given options and is the best choice.

The nurse is providing discharge instructions to a client with pernicious anemia. Which statement by the client demonstrates correct understanding of the at-home medication regimen? A "I will need vitamin B12 injections weekly for a month and then I can switch to an oral form of vitamin B12." B "Initially, I will need weekly injections of vitamin B12 and then monthly injections for maintenance, which will be a lifelong requirement." Correct Answer (Blank) C "When I start to feel weak, I will need to schedule an appointment at my provider's office for a vitamin B12 infusion." D "I will require one injection every 12 months until my vitamin B12 levels are therapeutic and then I'm done."

Rationale: A client with pernicious anemia cannot absorb vitamin B12 through the GI system, due to the lack of intrinsic factor needed to absorb B12. So taking supplements of vitamin B12 orally would not help with pernicious anemia. Therefore, the typical regimen for a client with pernicious anemia is to receive vitamin B12 through injections. Typically, the client will receive weekly injections until the hemoglobin is normal and then monthly, as maintenance. Clients with this type of anemia usually require lifelong treatment.

The nurse is teaching a group of clients diagnosed with arthritis about the use of non-steroidal anti-inflammatory agents (NSAIDs). In order to minimize the side effects of these drugs, which action should the nurse emphasize? A Eat a diet high in fiber B Take the medication with food Correct Answer (Blank) C Take the drug with an antacid D Limit foods high in vitamin K

Rationale: A common side effect of NSAIDs is gastrointestinal distress including heartburn, nausea, and stomach pain. Taking the medication with food will decrease this side effect. The other actions are not appropriate or indicated when taking NSAIDs.

A toddler ingested half a bottle of aspirin tablets. Which finding should the nurse expect to see in this child? A Epistaxis Correct Answer (Blank) B Dyspnea C Edema D Hypothermia

Rationale: A large dose of aspirin inhibits prothrombin formation and lowers platelet levels. With an overdose, clotting time is prolonged. Spontaneous bleeding often occurs from the nose or mucous membranes in the mouth. The other choices are not symptomatic of prolonged clotting time.

The nurse is caring for a client who is receiving patient-controlled analgesia via an epidural catheter. The infusion pump was started at 8 am and was set to deliver a basal rate of 1 mg per hour. When the nurse evaluates the client's pain level at 12 pm, the client reports that their pain level is unchanged from the morning. Which action should the nurse perform first? A Review pump settings and confirm proper functioning. Correct Answer (Blank) B Increase the basal rate to 5 mg per hour. C Notify the health care provider as soon as possible. D Encourage the client to use distraction and guided imagery.

Rationale: A patient-controlled analgesia (PCA) pump via an epidural catheter allows the client to receive a basal rate of pain medication, and also allows them to administer a dose of pain medication to themselves intermittently (i.e., bolus). All of the listed interventions are correct. However, the nurse should use the nursing process as a prioritization tool to first assess and determine that the pump is functioning correctly and that the medication has been infusing as it should have. Once the nurse has determined that the pump is functioning correctly, the health care provider (HCP) should be notified to ask for a potential increase in the medication dosage or change in medication. The nurse cannot just increase the rate without an order from the HCP. Nonpharmacological interventions, such as guided imagery and distraction, would also be appropriate for the client to use to help with pain management, but should not come first.

The nurse is teaching a client about an oral hypoglycemic medication. The nurse should place priority emphasis on which of the following points? A Distinguishing signs and symptoms of hypoglycemia and hyperglycemia B Taking the medication at specified times Correct Answer (Blank) C Adherence with recommended diet plan D Consulting with the health care provider about dose changes based on blood glucose

Rationale: A regular interval between doses should be maintained because oral hypoglycemics simulate the islets of Langerhans to produce insulin. If doses are not spaced correctly, insulin levels may increase, causing hypoglycemia, or decrease, causing hyperglycemia. The other actions are important and would be discussed after this initial point.

The nurse is providing instructions to a client with a new prescription for levothyroxine 50 mcg daily to treat hypothyroidism. Which of the following is important for the nurse to include in the discharge instructions? A It must be stored in a dark container. B It may decrease the client's energy level. C It can be taken with an antacid if stomach upset occurs. D It should be taken in the morning.

Rationale: A thyroid supplement should be taken in the morning on an empty stomach with 8 ounces of water to maximize effects. Also, the client should avoid foods high in fiber, iron or soybeans within four hours of taking this medication because they may interfere with this drug's absorption. The medication should not be given in the evening or prior to bedtime because it may cause insomnia. It is not necessary to keep in a dark container. As the medication replaces thyroid hormone the client's energy level should be improved not decreased.

The nurse is reviewing a new prescription for a client with conjunctivitis that reads: Administer ciprofloxacin solution 1 gtt OD Q4H. Which action should the nurse take next? A Squeeze one drop of the medication in the client's left eye every 4 hours. B Apply one drop of the medication in the client's right ear every 4 hours. C Contact the prescriber to clarify and rewrite the order. Correct Answer (Blank) D Ask another nurse for their interpretation of the order.

Rationale: Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every". Although "gtt" is not on the official "Do Not Use List", it is best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous workaround. The next action the nurse should take is to call the primary health care provider (HCP) who prescribed the medication and clarify the order.

A nurse is teaching a parent how to administer oral iron supplements to a 2-year-old child. Which intervention should be included in the teaching? A Administer the iron with your child's meals B Add the medicine to a bottle of formula C Give the medicine with orange juice and through a straw Correct Answer (Blank) D Stop the medication if the stools become tarry green

Rationale: Absorption of iron is facilitated in an environment rich in vitamin C. Because liquid iron preparation will stain teeth, a straw should be used. Parents should be informed that dark, tarry stools are expected outcomes of taking iron supplements. Iron is best absorbed on an empty stomach, but it may be given after meals if the child experiences an upset stomach.

The oncology nurse is preparing to administer the initial dose of vincristine to a child diagnosed with acute lymphocytic leukemia. Which interventions should the nurse include in the plan of care? Select all that apply. Apply pressure to the injection site if extravasation occurs Select the appropriate catheter for intrathecal administration Monitor for numbness or tingling in the fingers and toes Correct Answer (Blank) Monitor liver function tests regularly Correct Answer (Blank) Verify blood return before, during, and after intravenous administration Correct Answer (Blank)

Rationale: Acute lymphocytic leukemia (ALL) is the most common type of cancer in children and treatment protocols include vincristine, an anticancer drug. Vincristine is for intravenous use only; intrathecal (i.e., spinal) administration can be fatal. Vincristine is a vesicant that can cause significant local damage if extravasation occurs; treatment includes subcutaneous injection of an antidote and warm compresses, as topical cooling may worsen the effect. Peripheral neuropathy is a major side effect associated with vincristine. The nurse should monitor for decreased hepatic functioning because vincristine is metabolized in the liver.

The nurse in an ambulatory clinic is speaking with the parents of a 2-year-old child diagnosed with acute otitis media. Which information is most important for the nurse to include in the instructions to the parents? A The child should return to the clinic to evaluate effectiveness of the treatment. B The child may be given acetaminophen or ibuprofen drops for pain. C The child must complete the entire course of the prescribed antibiotic. Correct Answer (Blank) D The child may be given a decongestant to relieve pressure on the tympanic membrane.

Rationale: Acute otitis media (AOM) is an inflammation of the middle ear space with a rapid onset of the signs and symptoms of acute infection, namely, fever and otalgia (ear pain). It is one of the most prevalent early childhood illnesses. Treatment for AOM is one of the most common reasons for antibiotic use in the ambulatory setting. When antibiotics are necessary, it is most important to complete the entire course to prevent antibiotic resistance. The child should be seen after antibiotic therapy is complete to ensure that the infection has resolved. Supportive care of AOM includes treating the fever and pain. Decongestants or antihistamines are not recommended for children with ear infections.

The nurse is caring for a client who is prescribed methicillin sodium 1.5 g. The label reads to reconstitute with 5.7 ml of sterile water for a FINAL concentration of 500mg/ml. How many ml will the nurse administer with each dose?

Rationale: After the nurse reconstitutes the medication with sterile water, the supply available is 500 mg/ml. ml/dose = (1 ml / 500 mg) x (1000 mg / 1 g) x (1.5 g/dose) = 1500 / 500 = 3

The nurse is teaching a client with asthma about albuterol. How should the nurse best describe the action of this medication? A "The medication will help to relax smooth muscles in the airways." Correct Answer (Blank) B "The medication is given to reduce secretions that block airways." C "The medication will stimulate the respiratory center in the brain." D "The medication will help to prevent pneumonia."

Rationale: Albuterol is a bronchodilator and rescue drug of choice to treat asthma. It is a short-acting beta-adrenergic agonist that is used to prevent and treat wheezing, difficulty breathing, and chest tightness. Albuterol works by relaxing and opening the airways to make breathing easier. The medication comes as a tablet, syrup, inhaler and nebulizer. Albuterol does not reduce secretions, stimulate the respiratory center in the brain or prevent pneumonia.

The nurse is teaching a client diagnosed with asthma about the medication albuterol. Which statement by the nurse demonstrates appropriate teaching? A "Use this medication at bedtime to promote rest." B "Call your doctor's office if you need to use the drug more often." Correct Answer (Blank) C "Discontinue the inhaler if you feel dizzy." D "Use this medication after other asthma inhalers."

Rationale: Albuterol is a bronchodilator used for the relief of bronchospasm. It is considered a rescue medication for a client during an asthmatic attack. If the client notices the need to use the inhaler more frequently, the health care provider (HCP) should be notified. The client may need to seek emergency medical care, as the medication is no longer effective. In addition, clients should not exceed the recommended dosage, as adverse effects may occur. Be sure the client understands how to correctly use this medication. The client may experience side effects of dizziness, headache, nausea, vomiting, rapid heart rate, anxiety, sweating, flushing and insomnia. Using albuterol at bedtime may lead to insomnia. Albuterol should be used before all other inhalers, as it dilates the bronchi or bronchioles and allows more of the other medication to reach the lower respiratory tract. It would not be appropriate to suddenly discontinue taking a bronchodilator.

A woman diagnosed with bipolar disorder is to take lithium as part of her treatment. What should the nurse discuss with the client as part of the teaching plan? A Alcohol abstinence Correct Answer (Blank) B Weight reduction C Smoking cessation D Risk of concomitant use of oral contraceptives

Rationale: Alcohol potentiates the effects of lithium, resulting in central nervous system depression and impairment of judgment, thinking and psychomotor skills. The client should be cautioned to avoid drinking alcoholic beverages.

A client is prescribed alendronate. Which instruction should the nurse emphasize when teaching about this medication? A "Be sure to take this medication on an empty stomach." Correct Answer (Blank) B "Take the medication with a full glass of milk two hours after meals." C "It is recommended that you take this medication with calcium and a glass of juice." D "You may take this medication after any meal at the same time every day."

Rationale: Alendronate (Fosamax) is used to treat and prevent osteoporosis. It should be taken first thing in the morning with 6 to 8 ounces of plain water at least 30 minutes before other medication or food. Food and fluids (other than water) greatly decrease the absorption of this medication. The client must also be instructed to remain in the upright position for 30 minutes following the dose to facilitate passage into the stomach and minimize irritation of the esophagus.

The nurse is caring for a client with osteoporosis who has been prescribed alendronate. When providing care, which intervention would be a priority? A Notify the health care provider if the client reports jaw pain. Correct Answer (Blank) B Administer the alendronate 30 to 60 minutes before the client eats. C Encourage the client to increase their intake of vitamin D. D Monitor the client's serum calcium levels.

Rationale: Alendronate is a bisphosphonate that helps slow down bone resorption, decreasing osteoporosis. Osteonecrosis of the jaw is a rare, adverse reaction to alendronate, and jaw pain can be a symptom of this. Therefore, notifying the health care provider of the jaw pain is the priority. The other interventions are also correct for a client with osteoporosis, but are not as important as reporting the potential adverse drug effect.

A nurse is administering an intravenous piggyback infusion of penicillin. Which client statement would require the nurse's immediate attention? A "I have a burning sensation when I urinate." B "I am itching all over." Correct Answer (Blank) C "I have cramping in my stomach." D "I have soreness and aching in my muscles."

Rationale: Allergic reactions to medications can include itching all over. This can be further supported by the presence of hives or welts. Abdominal pain or cramping could indicate a side effect of the penicillin. The other symptoms of muscle soreness and painful urination are not as urgent as the itching.

The nurse is teaching a client with migraine headaches about almotriptan. Which statement by the client indicates that the teaching was effective? A "I will take the medication as soon as I notice migraine symptoms." Correct Answer (Blank) B "If the first dose does not help, I can take two more doses 15 minutes apart." C "I will take a dose every morning to make sure to prevent an acute attack." D "I will wait to take the medication until the pain has become unbearable."

Rationale: Almotriptan and other triptans are serotonin receptor agonists that work by causing vasoconstriction of intracranial arteries. The drug is most effective when taken as soon as migraine symptoms start but before the onset of acute pain. It will not prevent headaches or reduce the number of attacks. One of the most common side effects of this medication is dry mouth. After taking a dose, if the headache goes away and comes back, it is acceptable to take a second dose. The client should not take more than two doses of any triptan in 24 hours.

The nurse is caring for a client who was prescribed alprazolam. When educating the client about the new medication, which intended effect should the nurse include? A Reduce anxiety and provide a calming effect Correct Answer (Blank) B Reduce symptoms of depression C Increase coordination and the ability to concentrate D Alleviate signs and symptoms of spasticity

Rationale: Alprazolam is a benzodiazepine which is as an anxiolytic. The medication will not increase coordination and the ability to concentrate or alleviate symptoms associated with nerve damage, such as spasticity. Alprazolam will not reduce symptoms of depression.

The nurse is monitoring a client who is receiving the thrombolytic agent alteplase for treatment of an acute myocardial infarction (AMI). What outcome indicates the client is receiving adequate therapy within the first few hours of treatment? A Absence of cardiac arrhythmias B Reduction of ST-segment elevation on a 12-lead ECG Correct Answer (Blank) C Stabilization of blood pressure D Cardiac enzymes are within normal limits

Rationale: Alteplase (a t-PA) is used in the management of AMI with ST-segment elevation (STEMI). If thrombolytic therapy was successful, a follow-up ECG will show a reduction of 50% or more in the ST segment. This indicates a return in blood flow to the injured myocardium; however, the ST segment may not return to baseline due to myocardial damage. The other responses are incorrect: successful thrombolysis can cause a variety of cardiac arrhythmias; cardiac enzymes peak 8 hours or more after an AMI; and blood pressure may be unstable.

A client received 40 mg of furosemide by mouth at 10 am. Which information is most important for the nurse to provide to the next nurse in the change-of-shift report? A The client lost two pounds in the last 24 hours. B The client's urine output was 1500 mL over nine hours Correct Answer (Blank) C The client is to receive another dose of furosemide at 10 pm. D The client's potassium level was 4.0 mEq/L prior to administration.

Rationale: Although all of the information is important to include, a diuresis of 1,500 mL is a very large amount and could cause hypokalemia, fluid volume deficit and hypotension. Therefore, it is the most important information to provide to the nurse on the next shift.

The nurse is teaching a group of clients who have been diagnosed with schizophrenia about atypical antipsychotic medications. Which statement by the client would require further education by the nurse? A "I know I need to be patient but I wish it didn't take so long for this medication to really start working." B "I'm so glad that this medication won't cause any of the tremors or tics I had when I was taking my old medication." Correct Answer (Blank) C "I should be careful when I get out of bed because this medication can cause my blood pressure to drop." D "I'll probably gain a lot of weight on this medication and I may even develop diabetes."

Rationale: Although atypical antipsychotics may cause fewer extrapyramidal side effects, the client should know that they may still cause some of the same symptoms, like tics, slow speech, tremors or retarded movement. Most of these medications take two to four weeks or more to take effect. In addition to weight gain and developing diabetes, there is a risk for higher cholesterol and triglyceride levels.

The nurse is teaching a client with chronic renal failure about their medications. The client questions the purpose of taking aluminum hydroxide. How should the nurse respond? A "It decreases your blood's phosphate levels." Correct Answer (Blank) B "It is taken to control gastric acid secretions." C "It increases your urine output." D "It will reduce your blood's calcium levels."

Rationale: Aluminum binds to phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidneys. Antacids such as aluminum hydroxide are commonly used in clients with chronic renal failure to decrease serum phosphate levels. Aluminum hydroxide will not increase urine production, control gastric acid secretions or lower serum calcium levels.

A client with chronic obstructive pulmonary disease (COPD) is receiving aminophylline 25 mg/hour intravenously (IV). Which finding would be associated with the side effects of this medication? A Pruritus B Restlessness and palpitations Correct Answer (Blank) C Flushing and headache D Decreased urine volume

Rationale: Aminophylline is a bronchodilator often used to treat symptoms of asthma, bronchitis, and emphysema. Side effects include restlessness, palpitations, chest pain or discomfort, increased urine volume, vertigo, and vomiting. The other choices are not side effects of this drug.

The nurse is preparing to administer an intramuscular injection to a 1-year-old child. Where should the nurse give the injection? A Deltoid muscle B Dorso gluteal muscle C Vastus lateralis muscle Correct Answer (Blank) D Gastrocnemius muscle

Rationale: An intramuscular (IM) injection is an injection that is administered directly into the muscle. The vastus lateralis muscle is the preferred site for infants due to the large muscle mass at this location. The muscle lies along the lateral aspect of the thigh and is large enough to tolerate larger volumes of medication. The muscle is also not located near any nerves or blood vessels. Although the deltoid muscle is an option for IM injections, it is not the preferred site for infants. The other muscles are no longer recommended or appropriate for an IM injection.

A client with a history of heart disease has been prescribed prophylactic aspirin daily. Which action should the nurse implement to help prevent aspirin toxicity? A Teach the client that tinnitus is an expected side effect B Measure daily protein intake C Monitor serum albumin Correct Answer (Blank) D Assess serum potassium level

Rationale: Aspirin and salicylic acid are bound to serum albumin. A low serum albumin level may result in altered salicylate binding thereby increasing the availability of the unbound (active) drug for toxic effects. The effect is more evident in the elderly, especially someone with heart disease taking other medications that may be albumin-bound. Although aspirin can cause tinnitus and hearing loss, educating the client that this is an expected side effect is incorrect and would not prevent toxicity.

A client who recently had a heart attack has been prescribed low-dose (81 mg) aspirin at bedtime. The client states "Why am I supposed to take a 'baby aspirin' instead of a regular 325 mg tablet?" Which statement represents the nurse's best response? A "The higher dose will cause you to have heartburn." B "Taking a higher dose will affect your hearing." C "Taking 325 mg of aspirin daily will increase your risk of bleeding." Correct Answer (Blank) D "The higher doses may interfere with your normal sleep patterns."

Rationale: Aspirin is a nonsteroidal anti-inflammatory drug and is prescribed to help keep blood clots from forming after a heart attack. Lower-dose aspirin therapy is just as effective in reducing the risk of secondary heart attacks as higher doses of aspirin but with less risk of bleeding (including gastrointestinal bleeding.) This is especially important for the client to understand since he may also be prescribed an anticoagulant after his heart attack. Common side effects of aspirin therapy include rash, upset stomach, heartburn, drowsiness, and headache. Many drugs, including aspirin, can affect hearing; usually, much larger daily doses would be needed to affect hearing.

A client is being discharged with a prescription for warfarin. The client asks "May I take aspirin with this medication? It helps my arthritis." Which response by the nurse is appropriate to address the client's concern? A "Avoid aspirin because it can increase the bleeding effects of warfarin. Correct Answer (Blank) B "Take the warfarin in the morning and the aspirin at night." C "Use about half the recommended dose of aspirin." D "When you take the aspirin, do not take the warfarin that day."

Rationale: Aspirin is a salicylate, which inhibits platelet aggregation. When used in conjunction with warfarin, the risk of bleeding increases. Therefore, aspirin and warfarin should not be taken together. It is inappropriate to tell the client to not take the prescribed medication, warfarin.

The nurse is providing discharge education to a client who will be starting daily atenolol for the treatment of hypertension. The nurse should emphasize to notify the health care provider if which of the adverse effects occur? A Decreased libido B Decreased exercise tolerance C Slow, irregular heart rate Correct Answer (Blank) D Dizziness in the morning

Rationale: Atenolol is a Beta-1 selective adrenergic blocking agent or a "beta blocker." These medications are commonly used to treat hypertension or chronic angina. Due to their selectivity, they are the preferred medications for clients who have the comorbidities of Chronic Obstructive Pulmonary Disease (COPD). Common adverse effects often relate to the therapeutic action of the drug and include impotence, decreased libido, dizziness, decreased exercise tolerance, slowed heart rate, arrhythmias and heart failure. The client should be taught to assess their heart rate and to notify the health care provider of any changes to the heart rate or rhythm.

The nurse is caring for a client with chronic atrial fibrillation. Which drug does the nurse expect to administer to prevent a common complication of this condition? A Lidocaine B Diltiazem C Warfarin Correct Answer (Blank) D Carvedilol

Rationale: Atrial fibrillation puts clients at risk for developing emboli and is a major risk factor for an ischemic, i.e., thrombotic stroke. Clients at risk for emboli due to atrial fibrillation are treated with anticoagulants such as warfarin. The other drugs might be used for rate control of atrial fibrillation and as a "cardioprotective" medication, but they do not help prevent the development of a thrombus or embolus.

The nurse is caring for a client who has been prescribed atropine preoperatively. The nurse understands the intended purpose for administering this preoperatively is to induce which effect? A Elevate blood pressure B Decrease secretions Correct Answer (Blank) C Enhance sedation D Reduce heart rate

Rationale: Atropine is a common anesthesia adjunct. It decreases the number of secretions which, in turn, decreases the risk of aspiration during the operative procedure.

The nurse is preparing to administer newly prescribed albumin IV to a client who is on bedrest following surgery. Which statement should the nurse make to educate the client about the medication? A "This medication will prevent electrolyte imbalance." B "This medication will prevent tissue breakdown." Correct Answer (Blank) C "This medication will prevent dehydration." D "This medication will prevent malnutrition."

Rationale: Becoming immobile and inactive causes pressure on the skin and can result in skin breakdown. If pressure persists, tissue necrosis can occur, and pressure ulcers will develop. Serum albumin levels less than 3g/dl are associated with tissue edema and an increased risk of pressure ulcers. The infusion of albumin will help avoid tissue breakdown. Albumin IV will not prevent dehydration or electrolyte imbalance. Serum albumin levels can indicate that the client is experiencing malnutrition, but the medication will not prevent it.

The nurse is reviewing the medical record of a client who received a new prescription for benztropine. For which condition in the client's record should the nurse clarify the prescription with the health care provider? A Glaucoma Correct Answer (Blank) B Cataracts C Schizophrenia D Parkinson's disease

Rationale: Benztropine is an anticholinergic medication used to treat extrapyramidal disorders caused by antipsychotic medications or Parkinson's disease. The use of benztropine or other anticholinergics is contraindicated for individuals diagnosed with glaucoma, ileus, and prostatic hypertrophy. Adverse effects include tachycardia, urinary retention, and increased intraocular pressure.

A nurse is caring for a client who is scheduled to receive a unit of packed red blood cells. Which is an appropriate action by the nurse during the administration of the infusion? A Limit the infusion time to a maximum of four hours Correct Answer (Blank) B Slow the rate of infusion if the client develops a fever or chills C Store the packed red cells in the unit refrigerator while starting an intravenous (IV) line D Assess vital signs every 15 minutes for the duration of the infusion

Rationale: Blood should never be infused for longer than four hours due to the risk of bacterial growth in the bag. Similarly, once the blood has left the blood bank, it should never be stored in an unapproved refrigerator. If the client develops fever or chills, the blood should be immediately stopped, not slowed. Vital signs are typically checked every 15 minutes in the first 30 to 60 minutes of an infusion since most reactions occur within that time. After the first 30 to 60 minutes, vital signs should be checked at least hourly or per agency protocol until the transfusion is complete.

The nurse is providing discharge education to a client with moderate persistent asthma. The nurse should instruct the client to administer which medication first? A Mast cell stabilizer B Anticholinergic C Bronchodilator Correct Answer (Blank) D Glucocorticoid

Rationale: Bronchodilators, such as albuterol, are beta-agonist drugs that relieve bronchospasm by relaxing the smooth muscle of the airway. These medications should be inhaled first to open the airways, which will allow the other medications to move more deeply into the lungs and increase their effectiveness.

A nurse is caring for a client with a new order for bupropion hydrochloride for treatment of depression. The order reads "Wellbutrin 175 mg PO twice a day for four days." What is the appropriate action? A Monitor neurologic signs frequently B Observe the client for mood swings C Question this medication dose Correct Answer (Blank) D Give the medication as ordered

Rationale: Bupropion should be started at 100 mg twice a day for three days then increased to 150 mg twice a day. When used for depression, it may take up to four weeks for effective results. Common side effects are dry mouth, headache, and agitation. Doses should be administered in equally spaced time increments throughout the day to minimize the risk of seizures.

The nurse notes that a client's prescription was changed from captopril to losartan, even though the captopril provided effective blood pressure control. Which is the most likely reason for discontinuing the captopril? A Rash and itching B Dry cough Correct Answer (Blank) C Blurred vision D Sexual dysfunction

Rationale: Captopril is an ACE inhibitor that converts angiotensin I to the powerful vasoconstrictor angiotensin II in the renin-angiotensin-aldosterone system (RAAS). It is used in the management of hypertension and other cardiovascular diseases. A side effect of this medication is a dry cough, which many clients find intolerable. This is a common reason for a client's prescription to change from an ACEI to a similar medication such as an ARB (losartan). The other side effects are not typically seen with an ACEI drug.

The nurse is caring for a client with breast cancer who received chemotherapy one week ago. Which finding is the priority to report to the health care provider? A Fever and chills Correct Answer (Blank) B Depressed mood C Skin tenting of the forearm D Discomfort in both breasts

Rationale: Chemotherapy causes myelo or bone marrow suppression, resulting in neutropenia, the reduction in neutrophils (white blood cells) that fight off infections. Neutropenic, i.e., immunocompromised, clients are at an increased risk for infection, sepsis and septic shock and the nurse has to be extra vigilant in monitoring for early signs of infection. A fever and chills are indicative of a possible infection and take priority to be reported to the HCP. The other findings are also important to note and should be addressed by the nurse after notifying the HCP of the fever and chills.

The nurse is teaching a client with intractable hiccups about chlorpromazine. Which information should the nurse include? A Avoid tyramine-containing foods. B Avoid dairy products that contain lactose. C Avoid direct sunlight. Correct Answer (Blank) D Take on an empty stomach.

Rationale: Chlorpromazine is an antipsychotic medication in a group of phenothiazines. Principal indications for use are schizophrenia and other psychotic disorders. Other uses include suppression of emesis and relief of intractable hiccups. The most common adverse effects are sedation, orthostatic hypotension, and anticholinergic effects (dry mouth, blurred vision, urinary retention, photophobia, constipation, tachycardia). Photosensitivity reactions are possible; therefore, the client should be advised to avoid direct exposure to sunlight. The other instructions do not apply to this medication.

The nurse is providing discharge instructions to a client with a prescription for chlorpromazine. Which finding should the nurse teach the client to report immediately? A Insomnia B Fever Correct Answer (Blank) C Breast enlargement D Alopecia

Rationale: Chlorpromazine is used to treat schizophrenia and psychosis. The medication exhibits anticholinergic activity and alters the effects of dopamine in the central nervous system (CNS). A fever may indicate an infection due to agranulocytosis, a serious side effect of chlorpromazine. If white blood cell counts are low, the treatment should be stopped and antibiotic therapy started. Other common side effects of chlorpromazine include dry mouth and nasal congestion, extrapyramidal reactions, motor restlessness and hypotension. The other findings are not typically associated with this medication.

A client has been prescribed cholestyramine (Questran) in addition to other medications for coronary artery disease and hyperlipidemia. When should the nurse instruct the client to take the cholestyramine? A Early in the morning on an empty stomach B Anytime is acceptable C At least 1 to 2 hours after other medications Correct Answer (Blank) D At least 1 hour before meals

Rationale: Cholestyramine is a bile-acid sequestrant used to reduce LDL cholesterol levels. They are used primarily as adjuncts to statin therapy. Benefits derive from blocking cholesterol synthesis in the liver. The bile-acid sequestrants can form insoluble complexes with other drugs. Medications that undergo binding cannot be absorbed and hence are not available for systemic effects. Drugs known to form complexes with the sequestrants include thiazide diuretics, digoxin, warfarin, and some antibiotics. To reduce the formation of sequestrant-drug complexes, oral medications that are known to interact should be administered either 1 to 2 hours before the sequestrant or 4 hours after. Cholestyramine works best when taken with meals.

The nurse administers cimetidine to a 75-year-old client diagnosed with a gastric ulcer. The nurse should monitor the client for which adverse reaction? A Hearing loss B Increased liver enzymes C Mental status change Correct Answer (Blank) D Constipation

Rationale: Cimetidine is a histamine H2-receptor antagonist used to treat gastric ulcers. It has been found to cause confusion in susceptible clients, such as the elderly and debilitated clients. Clients over age 50 or who are severely ill may become temporarily confused while taking H2 blockers, especially cimetidine.

A nurse administers cimetidine to a 79-year-old male with a gastric ulcer. Which parameter may be affected by this drug and should be closely monitored by the nurse? A Blood pressure B Hemoglobin C Mental status Correct Answer (Blank) D Liver enzymes

Rationale: Cimetidine is an H2 receptor blocker used in treatment of gastric ulcers. Cimetidine should be used cautiously in the elderly, as it is known to cause a change in mental status such as confusion in the elderly population. Cimetidine does not impact the blood pressure, liver enzymes, or hemoglobin.

A client with angina has been instructed about the use of sublingual nitroglycerin. Which statement by the client indicates the need for additional teaching? A "I understand that the medication should be kept in the dark bottle." B "I can swallow two or three tablets at once if I have severe pain." Correct Answer (Blank) C "I will rest briefly right after taking one tablet." D "I'll call the health care provider if pain continues after three tablets five minutes apart."

Rationale: Clients must understand that just one sublingual tablet should be taken at a time. Clients must also understand that they should rest when experiencing angina. Two or three tablets should not be used at once, even in the setting of severe pain, as this can lead to significant hypotension. The client should notify their primary healthcare provider should they not have a relief of symptoms with nitroglycerin use.

The nurse is caring for a client who is receiving intravenous total parenteral nutrition (TPN). Which action by the nurse would represent appropriate care of this client? A Monitor for cardiac arrhythmias B Sterile technique for dressing change at IV site Correct Answer (Blank) C Maintain strict intake and output records D Record the number of stools per day

Rationale: Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are a good medium for bacterial growth. Strict sterile technique is crucial in preventing infection at IV infusion site.

The nurse is caring for a client who is prescribed an antipsychotic medication. Which statement correctly identifies why it is important for the nurse to monitor the client's blood pressure? A Rising trends in blood pressure will indicate when an antiparkinsonian medication is needed B Most antipsychotic medications cause wide fluctuations in blood pressure throughout the day C Orthostatic hypotension is a common side effect Correct Answer (Blank) D Blood pressure will determine if dietary restrictions should be implemented

Rationale: Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour after taking antipsychotic medication. Clients should be advised to get up slowly from a sitting or lying position.

A client has received a prescription for nitrofurantoin to treat a urinary tract infection. Which of the following statements made by the client indicates the need for additional teaching about the medication? A "I'll call my primary health care provider immediately if I develop a rash after taking the medication." B "I will spend extra time in the sun to get plenty of vitamin D." Correct Answer (Blank) C "I will be sure to finish taking the antibiotics, even if I start feeling better." D "I will take the medication with food."

Rationale: Clients taking nitrofurantoin should avoid exposure to sunlight while taking the medication. Exposure to sunlight while taking this medication can lead to damage to the skin. A client planning to spend extra time in the sun while taking nitrofurantoin should be informed of the dangers of sun exposure and counseled to avoid sun exposure while taking the medication. Client statements reflecting the importance of taking the complete course of antibiotics, notifying the health care provider if a rash develops and taking the medication with food demonstrate correct understanding of important considerations while taking this antimicrobial therapy.

The nurse is caring for a client who is actively dying and has been receiving high doses of opioid analgesics. The client has become unresponsive to verbal stimuli. What action should the nurse take? A Stop giving the analgesic B Give an extra dose of the analgesic C Continue the analgesic at the current dose Correct Answer (Blank) D Decrease the analgesic dosage by half

Rationale: Clients who are actively dying and have been experiencing chronic pain will probably continue to experience pain even though they cannot communicate this. Pain medication should be continued at the same dose as long as it is effective at that dose; some adjustments may be needed based on the client's physical manifestations of pain, such as grimacing or moaning.

A client at risk for a stroke has been prescribed clopidogrel. Which information is most important for the nurse to reinforce with the client? A "You must take the medication on an empty stomach." B "You must have your lab tests checked weekly." C "If you miss a dose, take a double dose the next day." D "You must stop the medication a week before your surgery."

Rationale: Clopidogrel is an oral antiplatelet drug with similar effects to aspirin. The drug is taken for secondary prevention of myocardial infarction, ischemic stroke and other vascular events. Clopidogrel prevents platelet aggregation. Like all other antiplatelet drugs, clopidogrel poses a risk of serious bleeding. Clopidogrel should be discontinued 5 to 7 days before elective surgery. The drug's effects begin two hours after the first dose and plateau after 3 to 7 days of treatment. Platelet function and bleeding time return to baseline 7 to 10 days after the last dose. It can be taken with or without food. No weekly lab tests are required with clopidogrel. Clients should not be instructed to double up when missing a dose.

A client recovering from hip replacement surgery is taking acetaminophen with codeine every three hours for pain. For which side effect should the nurse monitor the client? A Constipation Correct Answer (Blank) B Diffuse rash C Hyperglycemia D Wheezing

Rationale: Codeine is an opioid analgesic and antitussive (cough suppressant). For analgesic use, codeine is formulated alone and in combination with non-opioid analgesics (either aspirin or acetaminophen). Because codeine and non-opioid analgesics relieve pain by different mechanisms, the combination can produce greater pain relief than either agent alone. Opioids such as codeine slow down the function of the central nervous system. This can affect involuntary movements in the body, such as peristalsis. As the movement of food through the intestinal tract is slowed down, the walls of the intestine absorb more fluid. With less fluid in the intestines, stool becomes hard and constipation develops. The other side effects are not usually seen with codeine.

The nurse is caring for a client who had a central venous catheter inserted at the bedside. Which of these findings requires immediate intervention by the nurse? A Pallor in the extremities B Increased temperature by one degree C Dyspnea at rest Correct Answer (Blank) D Involuntary coughing spells

Rationale: Complications of central catheter insertion include pneumothorax and hemothorax. Air embolism is another potential complication. Dyspnea, shallow respirations, sudden sharp chest pain that worsens with coughing or deep breathing are indications of pneumothorax. Other potential complications of central catheters may include thrombosis, local or systemic infection, or even cardiac tamponade (if the central line perforates the heart). When considering the options listed, the client who is dyspneic after central line insertion would be the greatest concern for the nurse.

A nurse is caring for a client several days after a cerebral vascular accident (CVA). Coumadin has been prescribed. Today's prothrombin level is 40 seconds. Which finding requires priority follow-up? A Pharyngitis B Gum bleeding Correct Answer (Blank) C Anorexia D Generalized weakness

Rationale: Coumadin is an anticoagulant. The normal range of the prothrombin level is 10 to 14 seconds. This prothrombin level is elevated indicating the blood is taking longer to clot and presents a risk of internal bleeding. Generalized weakness post CVA is a normal finding. A sore throat (pharyngitis) and loss of appetite (anorexia) do not pose a serious risk at this time.

The nurse is providing education to the parents of a 10-year-old child who is diagnosed with diabetes insipidus (DI) and has been prescribed vasopressin. What priority information should the nurse include regarding this medication? A The child will need intravenous therapy for several weeks. B The family must monitor the child for arrhythmias. Correct Answer (Blank) C The child should be observed for dehydration. D Parents should administer the daily intramuscular injections.

Rationale: Diabetes insipidus is characterized by a decreased secretion of antidiuretic hormone (ADH). Decreased ADH results in polyuria and polydipsia; the person is unable to concentrate urine. Vasopressin is the drug of choice to treat central DI. At home, it can be administered 2-3 times a day, either IM, subQ, or intranasally. Not drinking enough fluids can cause arrhythmias, fatigue, and muscle pain. Other serious side effects include chest pain, skin discoloration, and paresthesia.

A client stung by a bee presents to the emergency department with difficulty breathing and swelling of the tongue. Which medication should the nurse anticipate to administer? A Diphenhydramine subcutaneous route B Methylprednisolone oral route C Epinephrine intravenous route Correct Answer (Blank) D Albuterol via nebulizer

Rationale: Difficulty breathing and swelling of the face, eyes, or tongue are severe and life-threatening allergic reactions to the bee sting. Epinephrine, 0.3-0.5 mL of a 1:1000 solution, should be administered immediately. The other medications are typically given as secondary interventions to help with bronchoconstriction and histamine release.

The nurse is caring for a client diagnosed with heart failure who will begin treatment with digoxin. Which therapeutic effect would the nurse expect to find after administering this medication? A Improved respiratory status with increased urinary output Correct Answer (Blank) B Increased heart rate with increased respirations C Decreased chest pain with decreased blood pressure D Diaphoresis with decreased urinary output

Rationale: Digoxin (Lanoxin), a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, indicated by findings of bradycardia or tachycardias above 120, arrhythmia, visual or gastrointestinal disturbances. Clients being treated with digoxin should have the apical pulse evaluated for one full minute prior to the administration of the drug.

The nurse is preparing to administer digoxin to a client with recurring atrial fibrillation. Which laboratory value should be of the highest concern for the nurse? A Serum potassium level of 3.1 mEq/L Correct Answer (Blank) B Serum creatinine level of 1.9 mg/dL C Hemoglobin level of 9.4 g/dL D B-type natriuretic peptide level of 140 pg/mL

Rationale: Digoxin is a cardiac glycoside used to treat atrial dysrhythmias and heart failure. Because digoxin competes with potassium ions, digoxin should not be given when the client's potassium level is below the normal range. Giving digoxin to a client with hypokalemia can cause digoxin toxicity and life-threatening cardiac dysrhythmias. Although all of the lab values are outside of the normal range, the low potassium level (normal range 3.5-5.0 mEq/L) should be of highest concern for the client at this time. The nurse should hold the digoxin and notify the health care provider.

The nurse is preparing to administer digoxin to a client admitted for acute decompensated heart failure. Which action is the priority before giving this drug? A Auscultate the lungs for crackles in the bases B Monitor oxygen saturation on room air C Assess the apical pulse for a full minute Correct Answer (Blank) D Assess the client's weight and compare to the baseline

Rationale: Digoxin, a cardiac glycoside, is used to slow the heart rate and increase the force of contraction. The priority for the nurse is to count the client's apical pulse for one full minute even if the heart rhythm is regular. Typically, when the pulse is less than 60, digoxin should not be given. The other actions are also appropriate assessments for a client with heart failure. However, they are not the priority when administering digoxin.

A client recently diagnosed with heart failure has been prescribed digoxin and furosemide. Which of the following foods should the nurse teach the client to eat at least one serving a day? A Pear nectar B Tomato juice Correct Answer (Blank) C Wheat cereal D Blueberries

Rationale: Digoxin, an antiarrhymic, and furosemide, a diuretic, are commonly prescribed for clients with heart failure. A common side effect for furosemide is depletion of potassium. Of the food choices, tomato juice is the highest in potassium. To reduce the risk of potassium depletion, the client should be encouraged to drink at least 1/2 cup of tomato juice every day which is about 400 mg of potassium. The other choices are low in potassium which would be recommended for clients diagnosed with chronic renal failure.

The nurse is preparing to administer diltiazem to a client with heart disease. Which action should the nurse take first? A Assess the client's urine output and potassium level B Assess the client's blood pressure and apical pulse Correct Answer (Blank) C Auscultate the abdomen for bowel sounds D Assess the client's lung sounds and monitor for wheezing

Rationale: Diltiazem is a calcium channel blocker that is used to treat hypertension, angina, and tachyarrythmias. The medication works by causing systemic vasodilation and lowering the client's heart rate. Common side effects of diltiazem include hypotension, orthostatic hypotension, bradycardia, edema, and headaches. It is not necessary to auscultate the client's lung sounds prior to administering the medication. Wheezing is not considered a side effect of diltiazem. Because the medication can lead to hypotension and bradycardia, it is essential to assess the client's blood pressure and apical pulse prior to administration. It is not necessary to check the client's urine output or potassium level prior to administering the medication. Diltiazem does not affect a client's renal status or potassium level. It is not necessary to check the client's bowel sounds prior to administering the medication. Diltiazem does not affect a client's gastrointestinal system.

The nurse is evaluating the plan of care for a client with benign prostatic hyperplasia (BPH). For which prescribed medication should the nurse notify the health care provider (HCP)? A Finasteride B Diphenhydramine Correct Answer (Blank) C Metoprolol D Terazosin

Rationale: Diphenhydramine is a first generation histamine1 receptor antagonist or antihistamine, commonly used for relief from symptoms of mild to moderate allergic disorders. H1 blockers have anticholinergic effects or atropine-like responses and can cause urinary hesitancy or retention. A client with BPH is already at risk for urinary retention and should not receive an antihistamine such as diphenhydramine without clarification from the HCP first. Metoprolol is a beta blocker, which does not affect the bladder. Finasteride and terazosin are drugs commonly used to treat BPH.

The nurse is providing discharge teaching to the parents of a 15-month-old child diagnosed with Kawasaki disease. The child received intravenous immunoglobulin therapy during the hospitalization. Which information should the nurse include? A Active range of motion exercises should be done frequently. B The measles, mumps and rubella vaccine should be delayed. Correct Answer (Blank) C High doses of aspirin will be continued for some time. D Complete recovery is expected within several days.

Rationale: Discharge instructions for a child with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis), should include the information that immunoglobulin therapy may interfere with the body's ability to form appropriate amounts of antibodies. Therefore, live or attenuated (weakened) immunizations should be delayed. The measles, mumps, and rubella (MMR) vaccine contains three live attenuated viruses and should be delayed until the child's immune system recovers from this treatment.

The nurse is completing a health history of a client diagnosed with Alzheimer's disease. The nurse reviews a list of the client's medications and supplements routinely taken at home. Which treatment should be a cause for concern by the nurse? A Coconut oil Correct Answer (Blank) B Ginkgo biloba C Omega-3 fatty acids D Donepezil

Rationale: Donepezil, rivastigmine, and galantamine are most commonly used in the treatment of Alzheimer's disease (AD). Complementary and integrative therapies use to treat AD include Gingko biloba (a plant extract) and omega-3 fatty acids. While there isn't sufficient research to support using these treatments, continued use won't necessarily be harmful. However, coconut oil, which is a source of caprylic acid, is a concern. While there has been limited research on Katasyn (an experimental drug containing caprylic acid), there is no scientific evidence that coconut oil is safe and effective or prevents cognitive decline.

The nurse in the urgent-care clinic is reviewing discharge instructions with a client who is prescribed doxycycline. Which statement by the client indicates understanding of the instructions? A "I will take this medication with an antacid to prevent an upset stomach." B "I will not wear my contact lenses while taking this medication." C "I will apply sunscreen when outside to prevent a sunburn." Correct Answer (Blank) D "I will carry glucose tablets with me in case I experience low blood sugar."

Rationale: Doxycycline is a tetracycline antibiotic. All tetracyclines can increase the sensitivity of the skin to ultraviolet light. The most common result is a sunburn. Clients on these types of medications should prevent sunburn by avoiding prolonged exposure to sunlight, wearing protective clothing and applying sunscreen to exposed skin while outdoors. This drug should be taken two hours before or after antacids, not with them. Hypoglycemia is not a common side effect of doxycycline. Wearing contact lenses is not contraindicated with this medication.

The nurse in a long-term care facility is preparing to administer medications. Which physiological changes does the nurse know will affect medication pharmacokinetics in older adults? A Due to a decrease in renal drug excretion, a greater risk for adverse medication effects exists. Correct Answer (Blank) B Due to an increase in glomerular filtration rates, medications are excreted more rapidly. C Due to an increase in metabolism, medications are prescribed more frequently D Due to a decrease in gastric emptying, higher medication doses are prescribed.

Rationale: Due to the physiological changes that occur as a person ages, older clients tend to be more sensitive to medications. Therefore, older clients must be monitored more closely for both desired and adverse responses, and their medication regimen must be adjusted accordingly. Aging-related organ decline affects drug absorption, distribution, metabolism and (especially) excretion. Although gastric acidity is reduced in older adults, altering the absorption of certain drugs, prescribing higher doses would not be appropriate. Because rates of hepatic drug metabolism tend to decline with age, prescribing a drug more frequently would lead to drug toxicity and adverse drug effects (ADEs). Renal drug excretion progressively declines due to a decrease (not an increase) in filtration rate as the person ages, placing elderly clients at greater risk for drug accumulation and ADEs.

The nurse is caring for a client who is prescribed erythromycin 500 mg orally every six hours for the treatment of pneumonia. The nurse should monitor the client for which common side effect? A Tendon rupture B Nausea and vomiting Correct Answer (Blank) C Esophagitis D Orange-red discoloration of urine

Rationale: Erythromycin is a macrolide anti-infective medication used that interferes with protein synthesis in susceptible bacteria. Nausea, vomiting, and gastrointestinal (GI) upset are common with erythromycin. The other side effects are not commonly seen with this drug.

The nurse is reviewing the medical history of a client who is receiving weekly erythropoietin injections. Which medical condition requires the use of this medication? A Sickle-cell disease B End-stage kidney disease (ESKD) Correct Answer (Blank) C Hemorrhagic fever (Ebola) D Iron-deficiency anemia

Rationale: Erythropoietin is a hormone that stimulates production of red blood cells (RBCs) in the bone marrow. The hormone is produced by cells in the proximal tubules of the kidneys. Erythropoietin can partially reverse anemia associated with chronic or end-stage renal failure. Initial effects can be seen within 1 to 2 weeks. Hemoglobin usually reaches acceptable levels (10 to 11 gm/dL) in 2 to 3 months. Erythropoietin is not used for iron-deficiency anemia, sickle cell disease or Ebola.

The nurse is teaching a client with rheumatoid arthritis about etanercept. Which of the following statements by the client indicates no further teaching is needed? A "If you keep the medication in a refrigerator, be sure to allow it to warm to room temperature before injecting it." Correct Answer (Blank) B "The medication needs to be mixed well. You can shake the bottle to mix it." C "You will need to come into the clinic every 6 weeks to receive an intravenous infusion." D "Take the medication daily, first thing in the morning on an empty stomach."

Rationale: Etanercept is in a class of medications called tumor-necrosis factor inhibitors and is used alone or with other medications to relieve the symptoms of some autoimmune disorders. It usually comes in a prefilled syringe and an automatic injection device. The medication is injected subcutaneously once a week. Besides knowing how and where to inject the medication, the client should be instructed never to shake the vial and, if the medication has been refrigerated, the nurse should reinforce that the client should simply place the medication on a flat surface (like a countertop) and allow it to warm to room temperature for about 30 minutes but never heat it in a microwave or place it in hot water.

The nurse in an emergency department is caring for a 3-week-old infant. During the initial assessment, the infant is crying and displaying furrowed brows and clenched fists. Which additional finding would indicate that the infant might be in pain? A Increased muscle tone Correct Answer (Blank) B Hyperglycemia C Constricted pupils D Ruddiness

Rationale: Evaluation of acute pain in an infant is partly based on physiological changes because the baby is unable to verbally self-report pain. The nurse should assess physiological manifestations in order to effectively assess and manage pain. Categories of physiologic responses noted during acute pain in a neonate include changes in vital signs, oxygenation, and others such as dilated pupils and increased muscle tone. Constricted pupils, ruddiness or hyperglycemia are not typical findings in a neonate experiencing pain.

The nurse is preparing to teach a client with type 2 diabetes mellitus about their newly prescribed exenatide (Byetta) pen. Which instructions should the nurse include? Select all that apply. You may experience some weight loss. Correct Answer (Blank) Take any oral medications 1 hour before the exenatide. Correct Answer (Blank) After use, store the injector pen in the refrigerator. Take the exenatide immediately after meals. Inject yourself in the abdominal or thigh area. Correct Answer (Blank)

Rationale: Exenatide (Byetta) is a non-insulin, incretin mimetic used for the treatment of diabetes. It works by lowering blood glucose by slowing gastric emptying, stimulating glucose-dependent insulin release, suppressing postprandial glucagon release, and reducing appetite. Some initial, minor weight loss is common. Exenatide comes in pre-filled, injector pens. Injections are made subcutaneously into the thigh, abdomen, or upper arm. Exenatide should be administered 0 to 60 minutes before the morning and evening meals — never after the meal. Exenatide delays gastric emptying and hence can slow the absorption of oral drugs; this is of particular concern with oral contraceptives and antibiotics. To minimize this interaction, the client should take oral drugs at least 1 hour before exenatide. Common side effects include nausea and vomiting. The pen should be stored at room temperature after first use.

A client is prescribed eye drops for treatment of glaucoma. What assessment is required before the nurse can begin teaching proper administration of the medication? A Determine the client's third-party payment plan B Evaluate the client's manual dexterity Correct Answer (Blank) C Identify the client's proximity to health care services D Assess the client's use of visual assistive devices

Rationale: Eye drops are prescribed to treat acute and chronic eye conditions, such as glaucoma. Eye drops are the mainstay of treatment, as they are administered directly at the site of action. Clients must become self-sufficient with eye drop administration. Often, ophthalmic administration of medications is more effective than oral administration of the same medication. Client education on proper instillation of eye medications is important. After a review of the procedure, a return demonstration by the client should be performed. The client's insurance has no relation to their ability to self-administer eye drops. Making sure that the client has ample support services is important, but it is not the most important aspect prior to learning how to self-administer eye drops. Clients must have adequate manual dexterity when self-administering eye drops. The drops need to be administered in an exact location and with aseptic technique. Although clients who suffer from visual disturbances need to use visual assistive devices, assessing their use of a device is not a higher priority than evaluating their manual dexterity.

The nurse is reinforcing the correct use of a metered-dose inhaler (MDI) for a client newly-diagnosed with asthma. The client asks, "how will I know the canister is empty?" What is the best response by the nurse? A "Drop the canister in water to observe if it floats." B "Count the number of doses as the inhaler is used." Correct Answer (Blank) C "Contact your pharmacy to find out when to obtain a refill." D "Shake the canister and listen for any fluid movement."

Rationale: Floating an MDI in water, or shaking it to listen for fluid movement to determine how much medication is left, is not recommended. MDIs that count down the number of remaining doses are available, however, these mechanisms are not always accurate. Therefore, it is best to calculate how long the inhaler will last by dividing the number of doses in the container by the number of doses the client takes per day. For example, a client who needs to take two puffs of albuterol, four times a day, will take a total of eight puffs per day. The MDI contains a total of 200 puffs. Divide 200/8 = 25 days. The inhaler in this example will last 25 days. To ensure that the client does not run out of medication, the client should obtain a refill at least 7 to 10 days before it runs out. The pharmacy would not be able to determine if the canister is empty.

A nurse is teaching a client with asthma about the correct use of the fluticasone inhaler. Which statement, if made by the client, would indicate that the teaching was effective? A "I should not use a spacer with my inhaler." B "I should rinse my mouth after using the inhaler." Correct Answer (Blank) C "If I forget a dose, I will double the next dose." D "The inhaler can be used when I feel short of breath."

Rationale: Fluticasone is an inhaled corticosteroid used to prevent asthma attacks. After using the inhaler, the client should rinse away any residue in the mouth to reduce the risk of an oral fungal infection. Fluticasone is not a bronchodilator and should not be used as needed for shortness of breath. The client should not double the dose of this medication and should use a spacer with this inhaler.

The nurse is providing preoperative teaching for a client preparing for a thyroidectomy about the medication saturated solution of potassium iodide (SSKI, ThyroSheild) drops. Which information is important for the nurse to include? A Store the medication in the refrigerator. B The medication will enlarge the thyroid gland. C Mix the medication with juice or milk. Correct Answer (Blank) D Take the medication on an empty stomach.

Rationale: For client's with Grave's disease, saturated solution of potassium iodide (SSKI) is given to control the hyperthyroidism, but also to reduce the amount of blood loss during surgery. The medication is in drop form, and the typical dosing is 1 to 2 drops three times a day mixed in juice or milk for 10 days preoperatively. It is not necessary to take it on an empty stomach. Storing it in the refrigerator may cause crystallization of the solution. The medication will not enlarge the thyroid gland.

The nurse is caring for a client diagnosed with deep vein thrombosis who is receiving a continuous intravenous heparin infusion. The client's baseline activated partial thromboplastin time (aPTT) prior to starting the heparin infusion was 24 seconds. The most recent aPTT result was 55 seconds. What action should the nurse take? A Maintain the current heparin infusion rate Correct Answer (Blank) B Administer a heparin antagonist (protamine) C Decrease the heparin infusion rate D Increase the heparin infusion rate

Rationale: For clients on a heparin drip, the therapeutic aPTT goal is generally 1.5 to 2.5 times the client's baseline. The client's baseline aPTT was 24 seconds and the therapeutic range for this client should be between 36 to 60 seconds. Since the client's aPTT is 55 seconds, within the therapeutic range, the nurse should maintain the current heparin infusion rate. The other actions would not be appropriate for this client.

The nurse is reviewing the laboratory data for a client who is receiving prescribed intravenous (IV) fluids to treat fluid volume deficit. Which result would indicate the fluid therapy has been effective? A Serum sodium level of 138 mEq/l Correct Answer (Blank) B Blood urea nitrogen (BUN) level of 26 mg/dl C Hematocrit (Hct) level of 56% D Urine specific gravity of 1.038

Rationale: For clients who are receiving prescribed IV fluids to treat fluid volume deficits, laboratory data can be used to determine if the fluid therapy is effective. In fluid volume deficits, the client will have low sodium levels and increased BUN, hematocrit, and urine osmolarity levels. A serum sodium level of 138mEq/l is within the normal range (135-145), indicating that the fluid therapy has been effective. Normal BUN is 6-20, normal hematocrit is 35%-47% for females and 39%-50% for males, and normal specific gravity is 1.010-1.025. The elevated BUN, Hct, and urine specific gravity levels indicate that the client is still experiencing fluid volume deficit.

Today's prothrombin time for a client receiving warfarin is 20 seconds. The normal range listed by the lab is 10 to 14 seconds. What is an appropriate nursing action? A Recognize that this is a therapeutic level. Correct Answer (Blank) B Notify the primary health care provider immediately. C Observe the client for hematoma development. D Assess for bleeding gums or IV sites.

Rationale: For the client on warfarin therapy, this prothrombin level is within the therapeutic range. Therapeutic levels for warfarin are usually one and a half to two times the normal level.

The nurse is caring for a client who has been taking furosemide for the past week. Which manifestation would indicate that the client may be experiencing a negative side effect? Decreased appetite Correct Answer (Blank) Gastric irritability Edema of the ankles Weight gain of five pounds

Rationale: Furosemide (Lasix) causes a loss of potassium if a supplement is not taken. Findings of hypokalemia include anorexia, fatigue, nausea, decreased gastrointestinal motility, muscle weakness and dysrhythmias.

The nurse has given discharge instructions to a client who suffers from sensory neuropathy due to diabetes. The client was prescribed gabapentin. Which of the following statements indicates that the client understands the nurse's instructions regarding the medication? A "It is safe to take extra doses if my pain becomes worse." B "I can stop taking the medication at any time." C "My doctor prescribed it for the pain in my legs." Correct Answer (Blank) D "The medication might cause me to have insomnia."

Rationale: Gabapentin is an anticonvulsant that can also be used for off-labeled purposes, such as for neuropathic pain syndromes (e.g., sensory neuropathy, postherpetic neuralgia). Taking gabapentin can lead to drowsiness and dizziness, not excitability and insomnia. Gabapentin should not be suddenly discontinued because that could lead to a seizure. Gabapentin is considered a first-line medication to treat neuropathic pain in people who suffer from sensory neuropathy and postherpetic neuralgia. Although uncommon, it is possible to overdose on gabapentin.

The nurse receives an order to administer intravenous gentamicin to a client. For which finding should the nurse contact the health care provider to clarify the order? A Low serum albumin B Low serum blood urea nitrogen C High serum creatinine Correct Answer (Blank) D High gastric pH

Rationale: Gentamicin is an aminoglycoside antibiotic that is excreted primarily by the kidneys. If there is reduced renal function as evidenced by the elevated serum creatinine level, the client is at greater risk for drug toxicity and further renal damage.

The labor and delivery nurse is caring for a 34-weeks gestation client with gestational hypertension who is receiving a continuous intravenous infusion of magnesium sulfate. What is the purpose of the infusion? A Increase the frequency of contractions B Maintain adequate respiratory function C Prevent preeclamptic seizures Correct Answer (Blank) D Help speed up fetal lung maturity

Rationale: Gestational hypertension can progress to preeclampsia and eclampsia. Eclampsia is defined as the development of convulsions in a woman with pre-eclampsia. Eclampsia can be prevented by giving magnesium sulfate. Magnesium sulfate is a central nervous system depressant that is used to prevent seizures. The literature has found that magnesium sulfate reduces the occurrence of eclampsia by 50%. The other actions are not related to magnesium sulfate.

A nurse is teaching parents of a child recently prescribed the medication phenytoin for seizure control. Which side effect will the nurse include? A Gingival hyperplasia Correct Answer (Blank) B Insomnia C Hypertension D Increased appetite

Rationale: Gingival hyperplasia (overgrowth of the gums) is a common side effect of phenytoin. Other common side effects include ataxia, central nervous system depression, drowsiness, headache, hypotension, mental confusion, nausea, vomiting, rash, and nystagmus.

The nurse is preparing to administer a liquid medication orally to a 9-month-old infant. Which of the following administration methods would be appropriate for the nurse to use? A Administer the medication with a syringe next to the tongue Correct Answer (Blank) B Mix the medication with the infant's formula in the bottle C Allow the infant to drink the liquid from a medicine cup D Hold the child upright and administer with a spoon

Rationale: Giving oral medications to an infant requires skill. The use of appropriate administration techniques is essential to prevent aspiration of liquid. Infants usually receive elixir or suspension forms that are administered using an oral syringe. First, the nurse should place the infant in an upright position. The nurse opens the infant's mouth by applying gentle pressure to the cheeks. The nurse should place the syringe in the infant's mouth along the side of the cheek, and then push the medication in slowly as the infant sucks. Using a needless syringe to slowly give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be decreased.

The nurse is caring for a client on a behavioral health unit. The client has received several doses of haloperidol for agitation and aggression related to acute psychosis. Before administering the next dose of haloperidol, the nurse assesses the client. Which findings indicate that the client is experiencing an adverse reaction to the drug? Select all that apply. Hyperthermia Correct Answer (Blank) Muscular rigidity Correct Answer (Blank) Sedation Diaphoresis Correct Answer (Blank) Redness at the site of injection

Rationale: Haloperidol is a typical or first-generation antipsychotic. Neuroleptic malignant syndrome (NMS) is one dangerous, life-threatening adverse drug effect associated with typical antipsychotics. Signs of NMS include muscular rigidity, hyperthermia, altered mental status and diaphoresis. Thus, these findings indicate that the client is experiencing an adverse reaction to the drug and the nurse should not give the medication and notify the health care provider. Redness at the site of injection is a common side effect but does not indicate a possible medical emergency. Sedation is a common side effect of typical antipsychotics and also does not indicate a possible medical emergency.

The nurse assesses a client who has been taking haloperidol for several months. Which of the following statements made by the client should be reported to the health care provider immediately? A "I occasionally have a dry, harsh cough." B "I'm having jerky movements with my arms that I can't control." Correct Answer (Blank) C "I'm having difficulties with falling asleep at night." D "My bowel movements have become harder and less frequent."

Rationale: Haloperidol is an anti-psychotic medication that blocks the effects of dopamine. It is used to treat schizophrenia, schizoaffective disorders and aggressive and agitated behaviors. Some of the most common side effects caused by this medication include nausea, vomiting, diarrhea, dry mouth, insomnia and blurred vision. Extrapyramidal side effects may also occur with the long-term administration of haloperidol. Of these effects, tardive dyskinesia is the most concerning because it is difficult to treat and may be irreversible. Tardive dyskinesia may result in tongue protrusions, muscle rigidity, and involuntary movements of the face and limbs. It typically resolves after the medication is discontinued. Severe tardive dyskinesia may affect the larynx and diaphragm, and may be life-threatening. Suspicions of tardive dyskinesia must be immediately reported to the health care provider.

The nurse in a hematology clinic is reviewing home medications for a child with hemophilia. Which medication should the nurse clarify with the health care provider? A Acetaminophen B Naproxen Correct Answer (Blank) C Prednisone D Diphenhydramine

Rationale: Hemophilia is a group of inherited bleeding disorders caused be a deficiency in clotting factors. Management is focused on replacing the missing clotting factor and prevention and control of bleeding. Naproxen is an NSAID that can affect platelet function and lead to an increased risk for bleeding. Clients should be educated not to take this medication when they have hemophilia. Corticosteroids, acetaminophen or diphenhydramine do not increase the risk for bleeding and are not contraindicated for a child with hemophilia.

A client is prescribed heparin therapy for deep vein thrombosis (DVT). Which laboratory value should the nurse monitor closely? A Bleeding time B D-dimer C Activated partial thromboplastin time Correct Answer (Blank) D Platelet count

Rationale: Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The activated partial thromboplastin time (APTT) test measures the time it takes blood to clot and is used to monitor the effectiveness of heparin therapy. The therapeutic range is about 1 1/2 to 2 or 2 1/2 times the normal values. D-dimer is used to evaluate blood clot formation. Platelet counts are used to evaluate abnormal bleeding times. Bleeding time refers to the time it takes for a pinprick to stop bleeding (normally about 2 1/2 minutes).

The nurse is preparing to administer a prescribed dose of lactulose to a client who has cirrhosis. Which lab value will the nurse monitor to evaluate the therapeutic effect of the medication? A Glucose B Ammonia Correct Answer (Blank) C Potassium D Bicarbonate

Rationale: Hepatic encephalopathy is a manifestation of liver disease that has neurotoxic effects of ammonia. Lactulose acidifies feces in the intestines, which traps ammonia that can be then eliminated with defecation.

A client received hydromorphone orally one hour ago. When the nurse enters the client's room, the client is unresponsive to verbal stimuli and has a respiratory rate of six breaths per minute. Which action should the nurse take next? A Administer supplemental oxygen. B Prepare to administer naloxone. Correct Answer (Blank) C Prepare for endotracheal intubation. D Begin cardiopulmonary resuscitation.

Rationale: Hydromorphone is an opioid analgesic. The client seems to be experiencing central nervous system and respiratory depression related to the medication. The antidote for opioids is naloxone. The nurse should first administer naloxone to reverse the effects of the hydromorphone. The other actions are not appropriate for the client at this time.

A one-year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? A Use aseptic technique during dressing changes B Monitor serum glucose levels Correct Answer (Blank) C Check results of liver enzyme tests D Maintain central line catheter integrity

Rationale: Hyperglycemia may occur during the first day or two as the child adapts to the high-glucose load of the TPN solution. Thus, a priority nursing responsibility is blood glucose testing.

The nurse is assessing a client who takes a prescribed antipsychotic medication. Which findings require immediate discontinuation of this medication? A Hyperthermia and severe muscle rigidity Correct Answer (Blank) B Agitation and constant state of motion C Cheek puffing and involuntary movements of extremities and trunk D Involuntary rhythmic stereotypic movements and tongue protrusion

Rationale: Hyperthermia, severe muscle rigidity and malignant hypertension are findings associated with neuroleptic malignant syndrome (NMS). NMS is a serious complication associated with the use of antipsychotic drugs. Repetitive, involuntary movements of the face or body may be a sign of tardive dyskinesia related to antipsychotic use. This is a serious concern, but not an emergency. Tardive dyskinesia may be irreversible, even after the medication has been discontinued. Agitation and being in a constant state of motion are most likely related to the illness being treated, such as bipolar disorder or schizophrenia.

A client has been taking isoniazid and rifampin for several months. Which laboratory test should the nurse monitor with this client? A Liver enzymes Correct Answer (Blank) B Sputum culture C Cardiac enzymes D Creatinine clearance

Rationale: INH and rifampin are used to treat tuberculosis and both are hepatotoxic. Isoniazid can cause hepatocellular injury and multilobular necrosis and is believed to result from the production of a toxic isoniazid metabolite. Rifampin is also toxic to the liver, posing a risk of jaundice and even hepatitis. Asymptomatic elevation of liver enzymes occurs in about 14% of patients. Hepatotoxicity is most likely in people who abuse alcohol and in clients with pre-existing liver disease. These individuals should be monitored closely for signs of liver dysfunction. Tests of liver function (serum aminotransferase levels) should be made before treatment and every 2 to 4 weeks thereafter. The other lab tests are not specific to the medications the client is taking.

A client diagnosed with an aplastic sickle cell crisis is within the initial 10 minutes of receiving a blood transfusion. The client reports "feeling hot." Almost immediately, the client begins to have audible wheezes. Which action should the nurse take first? A Stop and disconnect the blood infusion Correct Answer (Blank) B Notify the health care provider C Send blood samples to the lab D Take and record vital signs

Rationale: If a reaction of any type is suspected during the administration of blood products, stop the infusion immediately, disconnect the blood product line and connect a line with 0.9% normal saline at a keep open rate, notify the health care provider, monitor the vital signs and any other changes, and then send a urine and blood sample to the lab.

A client is newly diagnosed with bipolar disorder and has a prescription for lithium. Which point should the nurse be sure to emphasize? A Take other medication as usual B Maintain a salt-restricted diet C Report vomiting or diarrhea Correct Answer (Blank) D Substitute generic form if desired

Rationale: If dehydration results from vomiting, diarrhea, or excessive perspiration, the client may experience findings of toxicity due to a build-up of the drug. Lithium has a relatively narrow therapeutic index. Clients with serum lithium levels higher than 2 mEq/L should be admitted to the hospital.

A client with an intravenous (IV) antibiotic infusing is scheduled to have blood drawn at 1:00 pm for a peak antibiotic level measurement. The nurse notes that the IV infusion is running behind schedule and won't be completely infused until 1:30 pm. What action should the nurse take? A Increase the infusion rate to finish it by 1:00 pm B Reschedule the laboratory test for 2:00 pm Correct Answer (Blank) C Notify the client's health care provider D Stop the infusion at 1:00 pm and get the blood drawn

Rationale: If the antibiotic infusion will not be completed at the time the peak blood level is scheduled to be drawn, a nurse should ask that the blood sampling time be adjusted. Typically the peak level should be drawn about 30 to 60 minutes after completion of the infusion. The infusion should not be increased because in this situation the volume of fluid to be infused is unknown; rates for IV infusions should not be increased or decreased by more than 10% of the ordered rate. Trough and/or peak levels are commonly drawn for aminoglycosides (such as vancomycin, gentamicin, and tobramycin.)

The nurse prepares to administer a liquid medication to an infant. At the bedside, the parent states that the infant does not like to take medications. Which action should the nurse perform to ease the medication administration? A Give half the dose now and the remaining amount in an hour B Use an oral syringe to administer the medication, alternating with a pacifier. Correct Answer (Blank) C Mix the liquid medication with a full bottle of formula. D Ask the health care provider to switch the medication to an injection.

Rationale: Infants may struggle taking oral medications. Nurses should use a small syringe for liquid medications and administer to the side of the mouth. To encourage sucking, a pacifier or bottle nipple may be used intermittently with the medication. Liquid medications should never be added to a full bottle because the infant may not complete the feeding and receive a partial dose. Nurses should avoid stretching out medications as this will impact medication peak times. Developmentally appropriate techniques should be used before switching to a more invasive medication route.

A client diagnosed with iron deficiency anemia is prescribed ferrous sulfate suspension orally. Which instruction would be most appropriate for the nurse to give to the client regarding this medication? A "Diarrhea is a common side effect when taking this medication." B "Taking this medication will turn your urine dark orange in color." C "You should use a straw when taking this medication." Correct Answer (Blank) D "You should take the medication with food to enhance absorption."

Rationale: Iron deficiency anemia is the most common type of anemia. Treatment includes nutritional therapy, oral iron supplementation, and blood transfusions. Although diarrhea is a potential side effect of iron supplementation, the more common side effect of iron supplementation is constipation. Clients should take iron on an empty stomach for better absorption. Only in rare circumstances should clients take iron with food. Because liquid iron can stain the teeth, the most appropriate instruction is to use a straw. Iron medications do not cause discoloration of urine, but they can cause stool to turn black.

A client with anemia has a new prescription for ferrous sulfate. When teaching the client about diet and iron supplements, what should the nurse emphasize about taking an iron supplement? A Take the iron tablet with a glass of orange juice Correct Answer (Blank) B Take an antacid with the iron supplement to reduce stomach upset C Lie down for about 10 minutes after taking the pill D Take the iron tablet with a glass of low-fat milk

Rationale: Iron is best taken on an empty stomach, one hour before or two hours after meals, with a full glass of water or orange juice (ascorbic acid enhances the absorption of iron.) The client should not take the medication with antacids, dairy products, coffee or tea because these will decrease the effectiveness of the medicine. The client should not lie down for at least 10 minutes after taking the medicine.

The nurse receives an order to administer intravenous (IV) iron sucrose to a client with anemia. Which statement best describes the purpose of administering this medication using the IV route? To ensure that the entire dose of medication is given To prevent the drug from causing tissue irritation Correct Answer (Blank) To enhance absorption of the medication To provide more even distribution of the drug

Rationale: Iron sucrose is an iron supplement used to treat iron deficiency anemia. If given subcutaneously or intramuscularly, the tissue can become irritated and may result in bleeding into the muscle; therefore, the best route for this medication is intravenous (IV). The rate for administration will vary on the dosage but is typically at a slower rate due to the risk of adverse reactions. The other statements do not accurately describe the purpose for the IV route.

A client is being discharged with a prescription for an iron supplement. Which client statement indicates the need for further teaching by the nurse? A "I will take vitamin C along with the iron supplement." B "I will take the iron supplement with a full glass of milk." Correct Answer (Blank) C "I will not take antacids with my iron supplement." D "I will have greenish-black stools from the medication."

Rationale: Iron supplements should be taken along with vitamin C, such as orange juice because this increases absorption. Conversely, antacids, milk, caffeinated beverages, and calcium supplements can decrease the absorption of iron. Iron should be taken one hour before or two hours after meals to enhance absorption, although clients who report gastrointestinal intolerance may take it with food. Iron will cause stool to turn greenish-black and tarry.

The nurse is collecting data about a 20-year-old female client who has been prescribed isotretinoin for severe acne. The client states that she does not understand why she has to be seen monthly in the office to obtain a refill. What is the best response from the nurse? A "A monthly pregnancy test is required for all refills of this medication." Correct Answer (Blank) B "The medication is addictive and there is a maximum amount that can be dispensed." C "After a month the medication will expire and will have decreased effectiveness if taken. " D "When taking this medication, you must have your creatinine monitored monthly."

Rationale: Isotretinoin is highly teratogenic. The administration of isotretinoin is therefore closely monitored by the iPledge program, which has rules for the client, prescriber, pharmacist and wholesaler. The iPledge program is a pregnancy prevention program for isotretinoin, which has been linked to serious birth defects such as facial malformation, hydrocephalus and cardiac defects.

The nurse is reviewing a client's medication list and notes the client takes bupropion SR 150 mg oral twice a day. Which question is appropriate for the nurse to ask concerning the purpose of this medication? A "After taking this medication, did your hallucinations lessen?" B "Did your cravings for nicotine decrease after starting this medication?" Correct Answer (Blank) C "How much weight have you gained on this medication?" D "Have you had any abnormal dreams while taking this medication?"

Rationale: It is important for the nurse to know the generic name of drugs and their mechanism of action and therapeutic uses. Bupropion, when marketed as Zyban, is used as a nicotine-free method used to aid with smoking cessation. It should be started slowly and the dosage increased, but it should not be given for more than 12 weeks. Bupropion, when marketed as Wellbutrin, is used to treat depression. Side effects of bupropion are the same for either brand and include weight loss and insomnia. An alternative smoking cessation aid, varenicline, is associated with abnormal dreams and nightmares. Bupropion is not used for the treatment of hallucinations.

The nurse is planning care for clients over the age of 70. Which consideration would be most appropriate when planning care for older clients? Avoid drugs with side effects that impact cognition Review the drug regimen yearly Start with the smallest dose and increase slowly as needed Correct Answer (Blank) Do not stop a medication entirely

Rationale: It would be most appropriate for the nurse to consider starting with the smallest dose of the medication and slowly increasing as needed. Example: If a 70+ year old client is requesting pain medications and the order is for one or two tablets, the nurse should first administer one tablet and evaluate if the other tablet is needed. Due to physiological changes of the older client, medications can accumulate to toxic levels and cause serious adverse reactions. This could lead to altered mental status and risk for serious complications of the body's systems. The nurse should educate the client on their medications more frequently than just a year.

The nurse is assessing a client with tuberculosis who has been taking prescribed pyrazinamide. Which finding reported by the client should the nurse immediately report to the healthcare provider? Joint pain Fatigue Nausea Decreased appetite

Rationale: Joint pain is a symptom of gout, which is a side effect of pyrazinamide. While fatigue, nausea, and loss of appetite are common side effects of the drug, the joint pain is the priority.

A client with cirrhosis of the liver asks the nurse about the purpose of taking lactulose. How should the nurse respond? A "It is used to control portal hypertension." B "It helps to reduce ammonia levels in your blood." Correct Answer (Blank) C "It helps to regenerate your liver." D "It adds dietary fiber to your diet."

Rationale: Lactulose is a synthetic disaccharide that can be given orally or rectally. It blocks the absorption and production of ammonia from the gastrointestinal tract, reducing serum ammonia levels, and is used to treat hepatic encephalopathy. The other answers are incorrect.

The home health nurse evaluates a caregiver's technique for administering a rectal suppository to a client. The caregiver turns the client to the left side, pushes the lubricated suppository in with one finger, up to the second knuckle, removes the finger and then waits 10 minutes before turning the client to the right side. Which feedback from the nurse is most appropriate? A "Did you feel any stool in the intestinal tract?" B "Let's check to see if the suppository is in far enough." C "That was done correctly. Did you have any problems with the insertion?" Correct Answer (Blank) D "Why don't we now have the client turn back to the left side."

Rationale: Left side-lying position is the optimal position for clients to receive rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. The suppository should be somewhat melted after 10 to 15 minutes and the client can move into any position of comfort.

A nurse is administering lidocaine to a client with a myocardial infarction. Which assessment finding requires the nurse's immediate action? A Central venous pressure reading of 9 mmHg B Respiratory rate of 22 C Pulse rate of 48 beats per minute Correct Answer (Blank) D Blood pressure of 144/92

Rationale: Lidocaine can cause significant bradycardia and hypotension. A pulse of 48 beats per minute needs immediate attention and is often treated with atropine. At this time, the respiratory rate of 22 and blood pressure of 144/92 should be monitored. A normal central venous pressure ranges from 4 to 12 mm Hg. A central venous pressure above 12 may indicate hypervolemia or cardiac failure.

A client with bipolar disorder is taking lithium. The nurse should notify the health care provider when the client is prescribed which additional medication? A Furosemide Correct Answer (Blank) B Finasteride C Amlodipine D Insulin

Rationale: Lithium generally should not be taken with diuretics, especially a loop diuretic such as furosemide. The use of a diuretic will narrow the safe range for the lithium and adding a diuretic can lead to lithium toxicity. Additionally, side effects of lithium are polyuria and polydipsia. The nurse should clarify the order before administering lithium and furosemide together. Finasteride, amlodipine or insulin typically do not interact with lithium.

A client diagnosed with bipolar disorder is prescribed lithium. Which intervention would be essential for the nurse to emphasize when teaching the client about this medication? A .Use antacids to prevent heartburn B Maintain adequate daily salt intake Correct Answer (Blank) C Take the medication before meals D Reduce fluid intake to minimize diuresis

Rationale: Lithium levels need to be regularly monitored. Clients should be advised to drink 8 to 10 glasses of water or other liquids every day and keep their salt intake the same because too little salt may cause lithium levels to rise (and more salt may cause lithium levels to fall). Lithium is a naturally occurring mineral with an electrical charge similar to salt.

Which of the following statements by a client taking lithium for bipolar disorder indicates the need for additional teaching? A "I should let my health care provider (HCP) know if I have a lot of vomiting or diarrhea." B "I will be sure to drink about 6 to 8 glasses of water every day." C "I will need to have my blood drawn once a year to check the lithium level." Correct Answer (Blank) D "I will call my health care provider (HCP) if I have blurred vision or ringing in my ears."

Rationale: Lithium levels should be checked more frequently than once per year, with some sources recommending routine monitoring as often as every 1 to 2 months. The nurse would need to inform the client that it will be necessary to monitor lithium levels more often than once per year and coordinate with the HCP to identify the appropriate monitoring schedule for this client. Blurred vision, tinnitus, slurred speech and confusion could indicate a dangerous condition called lithium toxicity and the HCP would need to be notified immediately. Similarly, vomiting or diarrhea could increase the risk of dangerous levels of lithium in the blood. It is appropriate for clients taking lithium to drink 6 to 8 glasses of water each day.

The nurse is reinforcing teaching for a client diagnosed with asthma. Which statement indicates that the client understands the use of the prescribed long-acting beta2 agonist medication? A "I will take this medication daily to prevent an acute attack." Correct Answer (Blank) B "I will take this medication when I experience acute shortness of breath." C "I will take this medication as needed during allergy season." D "I will eventually be able to stop using this medication."

Rationale: Long-acting beta2 agonists (LABA), such as salmeterol, cause bronchodilation by relaxing bronchiolar smooth muscle and binding to and activating pulmonary beta2 receptors. Their onset of action is slow with a long duration. They are primarily used for the prevention of an asthma attack. The client will take this medication every day for the best effect. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will be required to take this medication long-term.

A client is prescribed a new antipsychotic medication. The nurse is teaching the client about possible side effects including tardive dyskinesia (TD). Which statement is accurate about tardive dyskinesia? A TD occurs within minutes of the first dose of any antipsychotic drug B The high fever, sweating, and muscle stiffness will last about one week C The longer someone is treated with an antipsychotic medication, the higher the risk for developing TD Correct Answer (Blank) D Almost every client treated with antipsychotic medications will eventually develop TD

Rationale: Long-term use of certain antipsychotic medications puts the client at a higher risk of developing TD. The symptoms are characterized by spastic movements of certain muscles, including the tongue, lips, jaw, and limbs. Early recognition by the health care provider, including the use of the Abnormal Involuntary Movement Scale (AIMS) is key. Once irreversible, there are now drug treatments, such as valbenazine, to treat the condition. It is estimated that up to 30 percent of clients taking antipsychotic medication will develop TD. The combination of high fever, sweating, and muscle stiffness indicates neuroleptic malignant syndrome, not TD.

The nurse is reviewing the medical record of a client with a new prescription for lovastatin for hyperlipidemia. Which finding requires the nurse to notify the health care provider immediately? A Alanine aminotransferase level of 90 U/L Correct Answer (Blank) B Serum creatinine level of 1.2 mg/dL C Total cholesterol level of 320 mg/dL D Hemoglobin A1c level of 10.2%

Rationale: Lovastatin is an HMG-CoA reductase inhibitor, commonly called a "statin," which is used for the treatment of hyperlipidemia and other cardiovascular diseases. Statins can be hepatotoxic and liver injury, as evidenced by elevations in serum transaminase levels, can develop. Normal alanine aminotransferase (ALT) levels range from 10 to 40 U/L. An ALT level of 90 is above normal and the nurse should notify the prescriber immediately. An elevated cholesterol level is an indication for treatment with lovastatin. The hemoglobin A1c level is also high but pertains to diabetes management, not the medication prescribed in this scenario. The creatinine level is normal.

The nurse is teaching a client who is receiving a monoamine oxidase inhibitor (MAOI) for clinical depression about potential side effects. Which intervention should the client implement to prevent potential adverse effects of the medication? A Avoid walking without assistance B Avoid chocolate and cheese Correct Answer (Blank) C Take the medication with milk D Take frequent naps

Rationale: MAO inhibitors are anti-depressants that affect neurotransmitters (chemical messengers between neurons). MAO inhibitors prevent the synthesis of monoamine oxidase, which eliminates the neurotransmitters dopamine, serotonin, and epinephrine from the brain. Due to the higher levels of these neurotransmitters, the client may experience an enhanced mood. MAO inhibitors impede the breakdown of tyramine. Tyramine is an amino acid that regulates blood pressure. Higher levels of tyramine can lead to a hypertensive crisis. An important intervention to stress for clients taking MAO inhibitors is to ensure that they limit the intake of tyramine-rich foods. Foods that are high in tyramine include chocolate, wine, and cheese. It is not necessary for a client to take MAO inhibitors with milk. Additional side effects from MAO inhibitors may include dizziness, weakness, and blurred vision. Although side effects may occur from these medications, it is not general practice to encourage clients to not walk without assistance or to take frequent naps.

The nurse is monitoring a client with hypomagnesaemia who is receiving electrolyte replacement intravenously. Which finding observed by the nurse would require immediate follow-up? A The infusion rate is set at 200 mg/min. Correct Answer (Blank) B The infusion is being infused with primary fluids of 0.9% normal saline. C The client has a potassium level of 3.5 meq/l. D The client also has a prescription for IV antibiotics.

Rationale: Magnesium sulfate should be given via infusion pump and should not be given at a rate that is higher than 150 mg/min. Magnesium sulfate is administered via a secondary line and is compatible with 0.9% normal saline. A potassium level of 3.5 is expected with a client who has hypomagnesemia. The prescription for IV antibiotics can be started after the magnesium is infused.

A client who has been receiving chemotherapy through a central venous access device (CVAD) at home, is admitted to the intensive care unit with a diagnosis of septicemia. Which nursing intervention is the priority? A Prepare the client for insertion of a new CVAD. Correct Answer (Blank) B Change the dressing over the site of the existing CVAD. C Place the client on contact precautions. D Insert an indwelling urinary catheter.

Rationale: Many cases of sepsis occur in immunocompromised clients and clients with chronic and debilitating diseases. Since it is likely that the existing CVAD is the source of the blood stream infection, it should be removed and the tip sent for culture and sensitivity testing. The nurse should anticipate this action and the priority is to prepare the client for insertion of a new CVAD. The other interventions are not indicated or appropriate for this client.

The nurse is providing care for a client diagnosed with a sickle cell crisis. Which prescribed medication should the nurse clarify with the health care provider? A Hydromorphone B Meperidine Correct Answer (Blank) C Morphine D Codeine

Rationale: Meperidine, an older opioid analgesic, is not recommended in clients with sickle cell disease. Normeperidine, a metabolite in meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates in the client's system. Clients with sickle cell disease are at high risk for normeperidine-induced seizures.

The nurse is teaching a client with systemic lupus erythematosus about methotrexate. Which statement by the client indicates an understanding of the medication? A "I should not use contraception that contains estrogen." B "I will not take any vitamin that contains folic acid." C "I will avoid interacting with people in large crowds." Correct Answer (Blank) D "Lab work won't be necessary while I take this medication."

Rationale: Methotrexate is an immunosuppressant medication that is used to treat systemic lupus erythematosus (SLE). Due to immunosuppression, clients taking methotrexate should avoid large crowds of people to prevent becoming ill. Methotrexate should be taken with folic acid to decrease gastrointestinal and hepatic toxicity. Clients who are taking this medication should have a complete blood count test done regularly to monitor for decreased white blood cells and platelets, which can indicate bone marrow suppression. Methotrexate is teratogenic, therefore, pregnancy should be avoided while taking this medication. Oral contraceptives that contain estrogen are not contraindicated with this medication or disease.

Nadolol is prescribed for a client with chronic stable angina. To evaluate whether the drug is effective, the nurse will monitor for which finding? A Fewer complaints of having cold hands and feet B The ability to do daily activities without chest pain Correct Answer (Blank) C Decreased blood pressure and heart rate D Improvement in the strength of the distal pulses

Rationale: Nadolol is a first-generation, non-selective beta-adrenergic antagonist (i.e., beta-blocker). Because the medication is ordered to improve the client's angina, it is considered effective when the client is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. Non-cardioselective b-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.

An 80-year-old client who is taking digoxin reports nausea, vomiting, abdominal cramps, and halo vision. Which laboratory result should the nurse evaluate first? A Blood urea nitrogen B Blood pH C Potassium levels Correct Answer (Blank) D Magnesium levels

Rationale: Nausea, vomiting, abdominal cramps, and halo vision are classic signs of digitalis toxicity. The most common cause of digitalis toxicity is a low potassium level. Clients are to be taught that it is important to have adequate potassium intake, especially if taking loop or thiazide diuretics that enhance the loss of potassium.

The nurse is teaching a client with stable angina about their new prescription for nitroglycerin transdermal patch. Which instructions should the nurse include? Select all that apply. A Plan for patch-free time, usually overnight Correct Answer (Blank) B Remove the patch if ankle edema occurs C Apply a second patch with chest pain D Notify your provider for persistent dizziness or any fainting episode Correct Answer (Blank) E Apply the patch to a hairless area of the body Correct Answer (Blank) F Rotate the application area

Rationale: Nitroglycerin (NTG) acts directly on vascular smooth muscle to promote vasodilation. It decreases the pain of exertional angina primarily by decreasing cardiac oxygen demand. NTG comes in a variety of routes of administration. NTG patches contain a reservoir from which the drug is slowly released. Following release, the drug is absorbed through the skin and then into the blood. The rate of release is constant and, depending on the patch used, can range from 0.1 to 0.8 mg/ hr. Effects begin within 30 to 60 minutes and persist as long as the patch remains in place (up to 14 hours). Patches are applied once daily to a hairless area of skin. The site should be rotated to avoid local irritation. Tolerance develops if patches are used continuously (24 hours a day every day). Accordingly, a daily "patch-free" interval of 10 to 12 hours is recommended. This can be accomplished by applying a new patch each morning, leaving it in place for 12 to 14 hours, and then removing it in the evening. NTG can cause orthostatic hypotension and the client should let their provider know if dizziness and lightheadedness persist or the client has a fainting (syncopal) episode as these may indicate that the NTG dose needs to be adjusted/decreased. The other instructions are not appropriate for this medication.

The nurse is providing discharge instructions to a client with a prescription for sublingual nitroglycerin. The nurse should inform the client to prepare for this most common side effect? A Anorexia B Dry mouth C Headache Correct Answer (Blank) D Depression

Rationale: Nitroglycerin is a potent vasodilator and a headache is the most common side effect. The headache comes on suddenly and can be severe, thus the client should be prepared for this effect. The other side effects listed are common side effects of oral medications, but not specifically to nitroglycerin.

A nurse is teaching a client with stable angina about newly prescribed SL nitroglycerin. Which statement should the nurse include in the teaching? A "Take this medication after each meal and at bedtime." B "Take one tablet 30 minutes before any physical activity." C "Take one tablet immediately when you experience chest pain." Correct Answer (Blank) D "Take this medication with 8 ounces of water."

Rationale: Nitroglycerin is a vasodilator used to treat angina or ischemic chest pain. When teaching a client about SL nitroglycerin, the nurse should instruct the client to take one tab and place it under their tongue immediately when experiencing chest pain. The client only takes this medication when experiencing chest pain. The client should not eat or drink when taking this medication.

Propranolol is prescribed for a client with coronary artery disease (CAD). The nurse should consult with the health care provider (HCP) before giving this medication when the client reports a history of which condition? A Myocardial infarction B Deep vein thrombosis C Asthma Correct Answer (Blank) D Peptic ulcer disease

Rationale: Non-cardioselective beta-blockers such as propranolol block b1- and b2-adrenergic receptors and can cause bronchospasm, especially in clients with a history of asthma. Beta-blockers will have no effect on the client's peptic ulcer disease or risk for DVT. Beta-blocker therapy is recommended after an MI.

The nurse is providing discharge education to a client diagnosed with coronary artery disease. The client is prescribed to use a nitroglycerin transdermal patch at home. Which statement by the client indicates a correct understanding of safe medication administration? A "I will keep a record of chest pain occurrences now that I have this patch." B "I will remove the old patch and cleanse the area before applying a new patch." Correct Answer (Blank) C "This drug can lead to hypertension. So, I will monitor my blood pressure at home." D "I can place this patch on broken skin. It will absorb better."

Rationale: Numerous administration errors have been reported with nitroglycerin paste and patches. The errors include improper storage and basic administration. The client should be taught to remove the previous patch before applying the new patch and to properly label the tube of nitroglycerin paste and keep it out of the reach of children. When selecting an area to place the patch, the skin should be intact and show no signs of irritation. Nitroglycerin paste has been used erroneously as lotion and caused toxic effects. Nitroglycerin causes vasodilation, which increases the blood supply through the coronary arteries. This may cause hypotension in clients. Some other common side effects include lightheadedness, nausea, dizziness, headache and redness or irritation of the skin covered by the patch.

A client with schizophrenia is receiving haloperidol 2 mg orally three times a day. The client approaches the nurse's station presenting with eyes rolled upward towards the head. The nurse recognizes this finding as what type of side effect? A Oculogyric crisis Correct Answer (Blank) B Nystagmus C Tardive dyskinesia D Dysphagia

Rationale: Oculogyric crisis is an acute dystonic reaction caused by some antipsychotic medications, including haloperidol. Tardive dyskinesia is also caused by antipsychotic medications but typically affects the muscles of the tongue, lips, jaw, and limbs. Nystagmus is an involuntary eye movement, and dysphagia is when one has difficulty swallowing. Neither of these conditions is directly caused by antipsychotic medications.

The nurse is caring for an 83-year-old client who is experiencing a sudden onset of confusion. Which medication most likely contributed to this change? A Cardiac glycoside B Antihistamine Correct Answer (Blank) C Liquid antacid D Anticoagulant

Rationale: Older adults are more susceptible to the side effects of anticholinergic medications, such as antihistamines. Antihistamines often cause confusion in the older adult, especially at high doses. Cardiac glycosides, anticoagulants and antacids are not associated with confusion or mental status changes in the older adult.

The nurse is caring for an 81-year-old client with colorectal cancer. Previously, the client's pain was managed with acetaminophen with codeine. However, the client is now experiencing frequent, severe pain, and intravenous morphine has been prescribed. What should the nurse recognize about this order? A Appropriate despite the risk of diarrhea and abdominal upset B Appropriate pain management and should be available around the clock Correct Answer (Blank) C Inappropriate and demonstrates lack of knowledge related to pain control D Inappropriate due to the potential of respiratory depression

Rationale: Older adults with cancer pain are frequently undermedicated. Pain management with IV morphine, while risky, is appropriate with proper assessment and monitoring of the client. The client should be started on the lowest effective dose, and the pain should be re-evaluated after administration. The nurse should assess the client for respiratory depression, constipation, and altered mental status.

The nurse is preparing to administer an albuterol nebulizer treatment to an 11-year-old child with asthma. Which assessment finding should be brought to the health care provider's attention prior to administering the medication? A Respiratory rate of 28 B Heart rate of 116 bpm Correct Answer (Blank) C Lower extremity edema D Temperature of 101 F (38.3 C)

Rationale: One of the more common adverse effects of beta-adrenergic medications, such as albuterol, is an increase in heart rate. Normal resting heart rate for children 10-years-old and older is the same as adults: 60 to 100 bpm. The nurse should report the heart rate to the health care provider prior to administering the medication.

The nurse is administering an osmotic diuretic to a client with a traumatic brain injury. Which finding best indicates that the medication was effective? A Intracranial pressure reading of 14 mmHg Correct Answer (Blank) B Bilateral ovoid pupils that are slow to constrict C Clear bilateral lung sounds to posterior auscultation D 250 mL clear, yellow urine output over four hours

Rationale: Osmotic diuretics, such as mannitol, are used to reduce intracranial or intraocular pressure. Intracranial pressure (ICP) for a client with a head injury should be less than 20 mmHg and the osmotic diuretic may be administered to reduce a high ICP. The osmotic diuretic will reduce the amount of water normally reabsorbed by the renal tubules and loop of Henle, so urinary output is increased, which is an expected occurrence, but does not indicate effectiveness of the medication. Ovoid pupils may indicate the presence of cerebral hypertension. An osmotic diuretic is not intended to reduce pulmonary edema, thus clear lung sounds are not an indicator for effectiveness of the diuretic for this particular client.

The nurse in an urgent care clinic is preparing discharge instructions for the parents of a 15-month-old child with a first episode of otitis media. Which information is the priority to include? A Provide a written handout describing the care of myringotomy tubes B Describe the tympanocentesis most likely needed to clear the infection C Explain that the child should complete the full 10 days of antibiotics Correct Answer (Blank) D Offer information on recommended immunizations around the child's second birthday

Rationale: Otitis media, an inner ear infection, commonly occurs in young children. Although not always caused by bacteria, many ear infections are treated with oral antibiotics. If a client is prescribed antibiotics, the priority is to make sure that they take the full prescription for the prescribed number of days to prevent recurrence or antibiotic resistance.

The nurse is giving instructions to the parents of a child who has cystic fibrosis. Which information should the nurse emphasize about the administration of pancreatic enzymes? A Crush the tablet and sprinkle on food three times a day B They are to be taken with every meal or snack Correct Answer (Blank) C Dispense once daily with breakfast D Administer each time a high-carbohydrate meal is eaten

Rationale: Pancreatic enzymes are necessary for digesting fat, starch, and protein. They should be taken with each meal and most snacks to allow for the proper digestion of the food. If taken on an empty stomach, they may cause gastric irritation and possibly ulcers. Enzyme capsules should be swallowed whole, not crushed or chewed, and the microspheres should not be sprinkled on or mixed with the whole meal.

Which prescribed medication for a client with chronic diarrhea should the nurse clarify with the health care provider? A Psyllium (Metamucil) 2.1 grams daily B Ferrous sulfate (Feosol) 325 mg daily C Senna (Senokot) 1 tablet every day Correct Answer (Blank) D Diphenoxylate with atropine (Lomotil) as needed

Rationale: Patients with diarrhea would not need a stimulant laxative such as senna. Senna [Senokot, Ex-Lax] is a plant-derived laxative that contains anthraquinones as active ingredients. Stimulant laxatives stimulate intestinal motility and increase the amount of water within the intestinal lumen producing a semifluid stool typically within 6 to 12 hours after administration. The other medications are not contraindicated with diarrhea. Paradoxically, methylcellulose, polycarbophil, and other bulk-forming laxatives can help manage diarrhea. Benefits derive from making stools firmer and less watery.

A client who is taking isoniazid for tuberculosis asks the nurse about the possible side effects of this medication. The nurse informs the client to report which side effect of this medication to the primary health care provider (HCP)? A Confusion and light-headedness B Double vision and visual halos C Extremity tingling and numbness Correct Answer (Blank) D Photosensitivity and photophobia

Rationale: Peripheral neuropathy is a common side effect of isoniazid and other anti-tubercular medications. Extremity tingling and numbness should be reported to the primary health care provider (HCP). Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral neuropathy due to isoniazid use.

The nurse is educating a client with seizure disorder about newly prescribed phenytoin. Which statement should the nurse include in the teaching? A "Blood work will be required if you have a seizure while taking this medication." B "You will need to have routine visits with a dentist when taking this medication." Correct Answer (Blank) C "It is normal to have a change in your gait when you first start this medication." D "Avoid grapefruit juice when taking this medication."

Rationale: Phenytoin is the first-line medication for the treatment of seizures. Clients should be instructed that they will need routine lab work to ensure that they are at a therapeutic level with the medication, even if they have been seizure-free. This medication can cause gingival hyperplasia, which will require routine dental visits. The client does not need to avoid grapefruit juice with this medication. Difficulty with hand and gait coordination could indicate toxicity and should be reported to the healthcare provider.

The nurse is caring for a client who is receiving procainamide intravenously. It is most important that the nurse monitors which parameter? A Hourly urinary output B Continuous ECG readings Correct Answer (Blank) C Serum potassium levels D Neurological signs

Rationale: Procainamide is used to suppress cardiac arrhythmias. When administered intravenously, it must be accompanied by continuous cardiac monitoring.

The nurse has administered fentanyl, atropine, cefazolin and benzocaine to a client for an endoscopic procedure. The nurse is monitoring the client and notes that the heart rate has increased from the pre-procedure baseline. The nurse knows that which of the following medications is most likely responsible for the client's increased heart rate? A Atropine Correct Answer (Blank) B Cefazolin C Fentanyl D Benzocaine

Rationale: Procedural sedation is used in endoscopic procedures as an effective way to provide an appropriate degree of pain and anxiety control; memory loss; and decreased awareness. The most commonly used medication regimen for gastrointestinal endoscopic procedure is still the combination of benzodiazepines, opioids, anticholinergics and topical anesthetics. Atropine is an anticholinergic drug that is used to dry secretions during the procedure. However, it can also increase the heart rate and dilate the pupils and is the most likely cause for the increased heart rate. Fentanyl is an opioid analgesic and short-term central nervous system (CNS) depressant and tends to slow breathing and lower heart rate and blood pressure. Benzocaine is a topical anesthetic and cefazolin is an antibiotic; neither should affect the heart rate.

A 42-year-old male client diagnosed with hypertension tells the nurse he no longer wants to take the prescribed propranolol. Which client statement best explains the reason why he does not want to take this medication? A "I'm having problems with my stomach." B "I feel so tired all the time." C "I'm experiencing decreased sex drive." Correct Answer (Blank) D "I have difficulty falling asleep."

Rationale: Propranolol is a beta-blocker used to treat many conditions, such as essential tremors, angina, hypertension and heart rhythm disorders. Common side effects of this drug include nausea, diarrhea, constipation, stomach cramps, rash, tiredness, dizziness, sleep problems and vision changes. Additionally, propranolol may cause decreased sex drive, impotence or difficulty having an orgasm in men. The clients can be switched to an alternative antihypertensive, such as an angiotensin-converting enzyme (ACE) inhibitor or a calcium channel blocker.

The nurse is providing information to a client about propranolol. Which statement by the client indicates the teaching has been effective? A "I can have a heart attack if I stop this medication suddenly." Correct Answer (Blank) B "I should expect to feel nervousness during the first few weeks." C "I could have an increase in my heart rate for a few weeks." D "I may experience seizures if I stop the medication abruptly."

Rationale: Propranolol is commonly used to treat hypertension, abnormal heart rhythms, heart disease and certain types of tremors. It is in a class of medications called beta blockers. Suddenly discontinuing a beta blocker can cause angina, hypertension, dysrhythmias, or even a myocardial infarction (i.e., heart attack).

The nurse is preparing a client with rheumatoid arthritis (RA) for discharge to an assisted living facility. Which statement about the prescribed oral glucocorticoid is correct? A "The medication will reverse the joint deterioration of RA." B "You will be taking the medication for several years." C "The medication will be gradually tapered off over 5 to 7 days." Correct Answer (Blank) D "It is normal to experience some memory loss or hallucinations."

Rationale: RA is an autoimmune, inflammatory disease that affects the joints. It is a progressive disease that causes joint deterioration and destruction, joint deformities and functional limitations for affected clients. The main goal of pharmacotherapy for RA is symptom relief. Glucocorticoids are anti-inflammatory drugs, which can relieve symptoms of RA and may also delay disease progression. For generalized symptoms related to RA, oral glucocorticoids are indicated. The most commonly employed oral glucocorticoids are prednisone and prednisolone. Glucocorticoids can slow disease progression, but will not reverse it. Treatment with glucocorticoids for RA is usually limited to short courses. Adverse psychological reactions such as hallucinations, memory loss or other psychoses must be reported to the provider and may require discontinuation of the glucocorticoid. To minimize adrenal insufficiency when glucocorticoids are discontinued, doses should be tapered very gradually.

The nurse is preparing to administer an antibiotic intramuscularly (IM) to a 2-year-old child. The total volume of the injection is 2 mL. Which is the best approach for the nurse to take when administering this medication? A Substitute an oral form of the medication. B Inject the medication in the deltoid muscle. C Split the medication into two separate injections. Correct Answer (Blank) D Call the provider and request a smaller dose.

Rationale: Recommendations for intramuscular (IM) medication administration for an infant/toddler (1 month to 2 years) include using a 1 inch, 22 to 25 gauge needle. The vastus lateralis muscle is preferred. The deltoid muscle should only be used if the muscle mass is adequately developed. IM injections for small children should not exceed a volume of 1 mL. For medication doses that exceed this volume, it is best to split the dose into two separate injections of 1 mL each. The other actions are not appropriate in this situation.

A client with a central line catheter is being discharged home. The nurse is teaching the client's partner how to change the central line dressing. Which is the best method to determine if the teaching was effective? A The partner return demonstrates a dressing change. Correct Answer (Blank) B The partner verbalizes the steps for changing the dressing. C The partner observes the nurse changing the dressing. D The partner watches a video about dressing changes.

Rationale: Return demonstration is the best method for determining if the teaching has been effective. The other methods are not as effective in determining if the partner understood correctly and is able to change the dressing. It is not appropriate to have the partner complete a quiz.

The nurse is caring for a client that is taking prednisone and aspirin for rheumatoid arthritis. Which action by the nurse is appropriate for this client? A Monitor the client's temperature every two hours B Apply a hot pack to a warm, acutely inflamed joint C Test the client's stool for occult blood Correct Answer (Blank) D Assess the client's pain level once a shift

Rationale: Rheumatoid arthritis is a chronic, progressive immunologic disorder. This type of arthritis is associated with progressive inflammation of joints and pain. The client's pain level should be assessed more often than once a shift. However, the client's temperature does not need to be measured every two hours. The client is at risk for gastrointestinal bleeding with the use of these two medications. The nurse should anticipate checking the stool for occult blood and monitor the client for signs and symptoms of anemia. When joints are acutely inflamed and warm on palpitation, the nurse should apply an ice pack, not heat.

A client is diagnosed with rheumatoid arthritis (RA). Which types of drugs might the nurse expect to be ordered as a combination drug therapy regimen? Select all that apply. Anti-inflammatory drugs Correct Answer (Blank) Antimicrobial agents Glucocorticoids Correct Answer (Blank) Diuretics Biological-response modifiers Correct Answer (Blank)

Rationale: Rheumatoid arthritis is a chronic, systemic autoimmune disorder that results in symmetric joint destruction. Research shows that multiple drug therapy is most effective in protecting against further destruction and promoting function. Analgesics and anti-inflammatory drugs are used. Disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate help slow or stop progression of RA. Biological response modifiers are used to help stop inflammation. Glucocorticoids can also be used for severe RA or when RA symptoms flare to ease the pain and stiffness of affected joints. Because RA is not an infectious disease, antimicrobials are ineffective. Although there is swelling in the joints, it is not fluid, so diuretics are not part of the treatment plan.

A client begins treatment with rifampin for suspected pulmonary tuberculosis. Which information should the nurse include when teaching the client about this drug? A "Avoid prolonged exposure to the sun while taking this drug." B "You may notice an orange-red color to your urine." Correct Answer (Blank) C "Check your radial pulse before taking the drug." D "It is important to stay upright for 30 minutes after taking this drug."

Rationale: Rifampin can cause a harmless reddish-orange discoloration of urine, feces, saliva, sweat, tears, skin, and even contact lenses. This effect can be very alarming for the client who may interpret it as some sort of bleeding. Understanding that this is a normal effect will promote adherence. The other instructions are not indicated when taking rifampin.

The nurse is discharging a client on oral potassium replacement. Which of the following statements requires further teaching by the nurse? A "I will continue to use salt substitutes to flavor my food." Correct Answer (Blank) B "I will take my furosemide first thing in the morning." C "I can still take my nonsteroidal anti-inflammatory medications occasionally for my arthritis pain." D "I will read the food labels for added potassium."

Rationale: Salt substitutes are made using potassium. As the client is taking potassium supplements, they should avoid salt substitutes to prevent hyperkalemia from occurring. NSAIDS can be used occasionally. The furosemide should be taken in the morning. Some low-sodium prepared foods may contain potassium, so reading the labels is important.

The nurse is caring for a client with sepsis receiving broad-spectrum antibiotics. Which finding might indicate to the nurse the need for a dosage adjustment? A Elevated creatinine level Correct Answer (Blank) B Elevated heart rate C Decreased white blood cell count D Decreased platelet count

Rationale: Septic shock is the most common type of distributive shock that threatens multi-system organ failure with a rapid onset, which is the leading cause of death in noncoronary ICU patients. Gram-negative bacteria have been the most implicated organism, and broad-spectrum antibiotics are given to help increase the likelihood of increasing tissue perfusion. The majority of broad-spectrum antibiotics are excreted through the kidneys, and an elevated creatine level will indicate the need for dosage adjustments. Elevated lactic acid levels, heart rate, and white blood cell (WBC) levels are all signs of sepsis and need to be monitored closely. Decreased platelet counts are seen when the condition is exacerbated with blood loss but does not affect the antibiotic dosage.

A newly admitted client reports taking phenytoin for several months. Which assessment should the nurse include in the admission report? Select all that apply. Report of unsteady gait, rash, and diplopia Correct Answer (Blank) Serum phenytoin levels Correct Answer (Blank) Report of anorexia, numbness, and tingling of the extremities Report of any seizure activity

Rationale: Serious adverse outcomes of antiseizure medications, such as phenytoin, are unsteady gait, slurred speech, extreme fatigue, blurred vision, or feelings of suicide. Clients who are prescribed phenytoin should have their levels monitored on a routine basis. The nurse should include any seizure activity as this may demonstrate a lack of a therapeutic level. Increased hunger (not anorexia), increased thirst, or increased urination are additional serious side effects.

The visiting nurse is evaluating the plan of care for a client who reports that they have decided to stop taking the recently prescribed sertraline due to frequent nightmares. Which action should the nurse take first? A Perform a suicide risk assessment Correct Answer (Blank) B Initiate transfer to the nearest psychiatric hospital C Explore alternative medications D Request for the medication to be changed to be given intramuscular

Rationale: Sertraline (Zoloft) is a selective serotonin reuptake inhibitor or SSRI, commonly used to treat depression, general anxiety disorder and other psychiatric disorders. Like all other antidepressants, SSRIs may increase the risk of suicide. To reduce the risk of suicide, clients taking antidepressant drugs should be observed closely for suicidality, worsening mood, and unusual changes in behavior. Close observation is especially important during the first few months of therapy and whenever antidepressant dosage is changed (either increased or decreased). SSRI are given orally, not IM.

The nurse is caring for a client who is prescribed lithium for bipolar disorder. Which clinical manifestations would indicate the client may be experiencing lithium toxicity? A Electrolyte imbalance, tinnitus and cardiac dysrhythmias B Vomiting, diarrhea and lethargy Correct Answer (Blank) C Ataxia, agnosia and coarse hand tremors D Pruritus, rash and photosensitivity

Rationale: Serum lithium levels should be between 0.8 and 1.2 mEq/L (remember, the exact numbers may vary slightly depending on the lab). Diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination may be early signs of lithium toxicity. Toxicity increases with increasing serum lithium levels, but clients may exhibit toxic findings at lithium levels below 2.0 mEq/L. Dehydration, other medications and other conditions can interfere with lithium levels.

The nurse is caring for a client admitted with sickle cell crisis. Which medication is the drug of choice for pain management with this client? A Hydromorphone Correct Answer (Blank) B Ibuprofen C Meperidine D Acetaminophen

Rationale: Sickle cell disease (SCD) is a genetic disorder that is characterized by hemolysis and sickling of red blood cells. A sickle cell crisis is considered an acute, severe exacerbation of the disease. During a crisis, individuals can develop severe pain and necrosis from the sickled cells that are accumulating within their blood vessels. As a result, clients should be treated with opioid pain medications during a crisis preferably administered intravenously. Hydromorphone (Dilaudid) is a strong opioid agonist indicated for moderate to severe pain. The other medications are indicated for more minor to moderate pain. Use of meperidine (Demerol) should be avoided so as to prevent the accumulation of normeperidine, a toxic metabolite.

The inpatient hospital nurse is caring for a client with hypokalemia. The health care provider prescribed a potassium intravenous (IV) infusion of 40 mEq potassium chloride in 250 mL normal saline to be infused over 4 hours. The nurse receives the infusion from the pharmacy. Which action should the nurse take next? A Notify the health care provider of the inappropriate dose of the prescribed IV potassium B Ask another nurse to verify the prescription, IV solution and serum potassium level Correct Answer (Blank) C Confirm patency of the peripheral venous access device and start the infusion D Ask another nurse to witness the addition of the prescribed potassium to the IV solution

Rationale: Since potassium chloride is considered a high alert medication, especially when given IV, having two nurses verify the order and IV bag is recommended. The nurses should compare the supplied IV bag to the prescriber's order. If potassium IV is infused too rapidly or in too high a dose, it can cause dysrhythmias and cardiac arrest. In addition, the second nurse should also verify the client's most recent serum potassium level to ensure that the prescription is appropriate. The prescribed dose and amount of IV solution is within normal range for IV potassium replacement therapy. Potassium should never be added by a nurse to an IV bag.

The nurse on an inpatient hospital unit is preparing to administer insulin aspart per sliding scale to a client whose most recent blood glucose level is 180 mg/dL. Which is the best time in relation to eating to give the insulin? Administer the insulin right before the client is about to start eating Correct Answer (Blank) B Administer the insulin immediately after checking the blood glucose level C Administer the insulin at any time before or after the meal D Administer the insulin 2 hours after the client has finished eating the meal

Rationale: Sliding scale insulin coverage typically consists of a short or rapid acting insulin and is generally prescribed to be given "AC" (ante cibum) or before meals. The client should begin eating within minutes of receiving the insulin due to the rapid onset of insulin aspart (ranging from 10 to 20 minutes) to prevent hypoglycemia. Therefore, the nurse should first determine that the client's meal has arrived and the client is about to start eating. If the client receives the insulin but the meal is delayed for some reason, the client may become hypoglycemic. Insulin aspart peaks at around 1 to 3 hours after administration. The other times are not appropriate to administer the insulin.

The caregiver of a client with Alzheimer's disease asks the nurse for information about different treatment options that can help with memory or behavior problems. Which of the following responses by the nurse are correct? Select all that apply. "Music therapy has been found to help some clients." Correct Answer (Blank) "Donepezil (Aricept) may help slow cognitive decline." Correct Answer (Blank) "Garlic may help with this disease." "Ginkgo biloba may help with memory." Correct Answer (Blank) "Acupuncture may be very relaxing."

Rationale: Some complementary and integrative health therapies may help with the symptoms of Alzheimer's disease. Music, art and dance therapies can help with behavior issues. Ginkgo biloba may be used to improve memory. Acupuncture may be a frightening experience for someone with Alzheimer's disease. Garlic is not a treatment for Alzheimer's disease. Donepezil (Aricept) is used to ease the symptoms associated with Alzheimer's disease.

The nurse is caring for a client with inflammatory bowel disease who admits to using complementary therapies including herbal remedies and peppermint tea. Which of the following statements should the nurse make? A "I would suggest that you discontinue the use of these therapies as they may be dangerous." B "These therapies are known to interfere with prescribed medications, so it is important to stop using them." C "It is important to inform your health care provider of the use of these therapies." Correct Answer (Blank) D "These therapies are probably not harmful but may be costing you unnecessary money."

Rationale: Some herbal remedies including peppermint tea and peppermint oil have been shown to relieve symptoms of irritable bowel syndrome. However, they may interact with prescribed medications. The health care provider needs to be aware of the use of all complementary and integrative health therapies, so an informed decision can be made if it is safe to continue them or not.

The nurse is administering spironolactone for a client diagnosed with cirrhosis of the liver and ascites. Which electrolyte should the nurse anticipate to be spared when giving this medication? Sodium Albumin Potassium Correct Answer (Blank) Phosphate

Rationale: Spironolactone is a potassium-sparing diuretic. Indications for this medication include edema associated with heart failure, cirrhosis, and nephrotic syndrome. The nurse should anticipate that potassium is spared and should watch for signs of heart arrhythmias if the potassium is too elevated. This type of diuretic inhibits the action of aldosterone on the kidneys, which does not allow the body to reabsorb sodium. An adverse effect could be hyponatremia. This medication has no effects on phosphate and albumin is not an electrolyte.

Which of the following instructions is most important for the nurse to include when discharging a client with an infection caused by staphylococcus? A Complete the full course of the antibiotic Correct Answer (Blank) B Visit the provider in a few weeks C Schedule follow-up blood cultures D Monitor for signs of recurrent infection

Rationale: Staphylococcus is a bacteria and to rid the body of the infection, it is most important to instruct the client to complete the full course of antibiotics. Not completing the full course of antibiotics can lead to antibiotic resistant infections. At this point, there is no indication for the need for blood cultures. The client will need a follow-up appointment with the provider, and will need to monitor for signs of recurrent infections, but these are not as high a priority as completing the full course of antibiotics.

A nurse is assessing a 9-year-old child after several days of treatment for a documented strep throat. Which statement is incorrect and suggests that further teaching is needed? A "Sometimes I take my medicine with fruit juice." B "I am feeling much better than I did last week." C "Sometimes I take the pills in the morning and other times at night." Correct Answer (Blank) D "My mother makes me take my medicine right after school."

Rationale: Strep throat is a bacterial infection that is treated with antibiotics. It is important to take antibiotics on a regular schedule and at approximately the same time each day. Depending on the medication, it is OK to take it with food or juice. The client should be feeling better after several days of antibiotics —however should be cautioned to complete the prescribed amount.

A child is treated with succimer for lead poisoning. Which of these assessments is the priority? A Check the client's blood calcium level. B Check the client's complete blood count with differential. Correct Answer (Blank) C Test the client's deep tendon reflexes. D Check the client's serum potassium level.

Rationale: Succimer is used in the management of lead or other heavy metal poisoning. Although it is generally well-tolerated and has a relatively low toxicity, it may cause neutropenia. Succimer therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1,200/mm3. The normal range for an ANC is 1.5 to 8.0 (1,500 to 8,000/mm3). Therefore, the assessment priority in this scenario is checking the complete blood count (CBC) with differential which includes an ANC value.

The nurse obtains a new order to infuse 20 mEq of potassium chloride IV piggyback for a client with a serum potassium of 3.2 mEq/L (3.2 mmol/L). While reviewing the client's cardiac monitor, which ECG finding best indicates that the infusion of potassium should be stopped? A Tall, peaked T waves Correct Answer (Blank) B Shortened PR interval C Narrowed QRS complex D Prominent U waves

Rationale: Tall, peaked T waves are a finding in hyperkalemia, and would necessitate a change in IV solution, to eliminate the potassium. If the potassium infusion were to continue it could cause worsening hyperkalemia and possible cardiac arrhythmias. The nurse should notify the health care provider of the ECG finding, and should request an order for a different IV solution without potassium. In addition, a stat serum potassium should be done to assess the severity of the hyperkalemia and to determine whether further intervention to reduce the potassium level is required. In conjunction with this, a serum creatinine should be checked to determine whether worsening renal function may have reduced potassium excretion, contributing to this new electrolyte abnormality.

The nurse is caring for a client who received tenecteplase to open an occluded coronary artery. Which finding should be of the highest concern for the nurse? A Bleeding gums B Urinary retention C Hematemesis Correct Answer (Blank) D Epistaxis

Rationale: Tenecteplase, a thrombolytic agent, breaks down a thrombus by stimulating the plasmin system. The plasmin system is a natural anticlotting system, which breaks down fibrin and dissolves any clots. Since this medication is not specific to a certain type of clot, the client should be expected to have an increased bleeding risk after administration. The most common adverse effect of thrombolytic medications is bleeding and hemorrhage. The nurse should monitor the client for signs and symptoms of abnormal bleeding. Hematemesis means vomiting blood. This is usually related to a bleeding gastric ulcer and should be of the highest concern. Epistaxis (nose bleed) and bleeding gums are usually minor bleeding and can be easily monitored by the nurse.

The health care provider has prescribed tetracycline for a 28-year-old female client with severe acne. When teaching the client about this medication, which information is important for the nurse to include? A It may decrease the effectiveness of oral contraceptives. Correct Answer (Blank) B It should be taken with food or milk. C It may cause staining of the teeth. D It may cause hearing loss.

Rationale: Tetracycline, a broad-spectrum antibiotic, can decrease the effectiveness of oral contraceptives; therefore, it is important to recommend use of an additional form of contraception such as a condom when taking this medication. Tetracycline should be taken on an empty stomach and never with milk. It is not given to children younger than 8 years old because it can stain developing teeth. Tetracycline is not known to cause hearing loss

A client calls the clinic and states to the triage nurse: "I had an upset stomach and took Pepto-Bismol and now my tongue looks black. What's happening to me?" What would be the nurse's best response? A "This is a common and temporary side effect of this medication." B "Come to the clinic so you can be seen by the health care provider." Correct Answer (Blank) C "How long have you had an upset stomach?" D "Are your stools also black?"

Rationale: The best response would be to explain that a dark tint of the tongue is a common and temporary side effect of bismuth subsalicylate (Pepto-Bismol). Although it may also turn stools a darker color, do not confuse this with black, tarry stools, which is a sign of bleeding in the intestinal tract. After addressing the client's initial concern and the reason for the call, the nurse can ask about the upset stomach and then ask the client to come to the clinic if necessary.

A nurse is educating a client who was prescribed a monoamine oxidase inhibitor (MAOI) for depression to avoid foods high in tyramine. Which foods should the client avoid? A Apple juice, ham salad, fresh pineapple B Hamburger, fries, strawberry shake C Red wine, raspberries, aged cheese Correct Answer (Blank) D Fresh juice, carrots, vanilla pudding

Rationale: The body has two forms of MAO, named MAO-A and MAO-B. In the brain, MAO-A inactivates norepinephrine (NE) and 5-HT, whereas MAO-B inactivates dopamine. In the intestine and liver, MAO-A acts on dietary tyramine and other compounds. Although the MAOIs normally produce hypotension, they can be the cause of severe hypertension if the client eats food that is rich in tyramine. The client must be given a detailed list of tyramine-rich food and beverages to avoid, including avocados, figs, smoked meats, liver, processed deli meat such as salami and bologna, red wine, and practically all cheeses.

A client is receiving total parenteral nutrition (TPN) via a tunneled catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? A Check that the catheter tip is intact B Apply a pressure dressing to the site Correct Answer (Blank) C Monitor respiratory status D Assess for mental status changes

Rationale: The client is at risk of bleeding or developing an air embolus if the catheter exit site is not covered with a pressure and occlusive dressing. An occlusive dressing is one that is totally covered by adhesive tape around the edges, as well as over the entire dressing.

The nurse is providing education to a client that will be discharged with a prescription for sublingual nitroglycerin as needed for acute angina. The nurse should include which of the following in the teaching? A If acute angina occurs, stop activity and take the medication as directed Correct Answer (Blank) B Keep the medications locked in a cabinet at their home C If pain is not relieved after the sixth dose, call 911 D Drink a glass of water immediately after placing the tablet under the tongue

Rationale: The client should be taught the correct self-administration of nitroglycerin during acute angina. On the onset of angina, the client should stop activity and place the nitroglycerin under their tongue. Three sublingual nitroglycerin tablets should be taken in 5-minute increments. If the pain is not relieved the client may be experiencing a myocardial infarction and needs to call 911. Drinking a glass of water with the nitroglycerin could decrease sublingual absorption. The nitroglycerin should not be kept at home, but carried with the client. The client should be told to call 911 if the pain is not relieved after 3 doses, not 6.

The nurse is teaching the client how to properly use a dry powder capsule inhaler. How should the nurse instruct the client to use this type of inhaler? A Seal lips tightly around mouthpiece and inhale rapidly and deeply Correct Answer (Blank) B Breathe in medicine slowly and deeply for about 3-5 seconds C Rinse mouthpiece in hot soapy water after using D Shake inhaler before putting it in mouth

Rationale: The client should breathe in quickly and deeply for up to 10 seconds when using a dry powder capsule inhaler. The client should not shake this type of inhaler. The mouthpiece can be rinsed with warm water but without soap or detergent.

The nurse is caring for a client who is receiving a continuous intravenous heparin infusion. The client's most recent activated partial thromboplastin time (aPTT) is 120 seconds. Which medication should the nurse plan to administer? A Protamine Correct Answer (Blank) B Naloxone C Enoxaparin D Vitamin K

Rationale: The client's aPTT is much higher than the typical desired therapeutic range of 1.5-2.5 the control value and places the client at great risk for uncontrolled bleeding. Protamine sulfate is the medication used to reverse the effects of heparin; it is a heparin antagonist. Neutralization of heparin occurs immediately and lasts for 2 hours, after which additional protamine may be needed. Protamine is administered by slow IV injection (no faster than 20 mg/ min or 50 mg in 10 minutes). Dosage is based on the fact that 1 mg of protamine will inactivate approx. 100 units of heparin. Vitamin K is used to reverse the effects of warfarin. Naloxone is used to reverse the effects of opioids. Enoxaparin is another anticoagulant (low molecular weight heparin).

The nurse is evaluating an older adult client with an upper gastrointestinal bleed who received several packed red blood cell transfusions in the past 24 hours. Assessment findings include crackles to auscultation, bounding pulses, orthopnea and an oxygen saturation of 90% on room air. Vital signs include heart rate of 106 bpm, blood pressure 160/80 mm Hg, respirations 24 and temperature 98.6o F (37o C). Which adverse transfusion reaction is the client most likely experiencing? A Hemolytic transfusion reaction B Circulatory overload Correct Answer (Blank) C Transfusion-associated graft-versus-host disease D Bacterial transfusion reaction

Rationale: The client's symptoms are most likely related to circulatory overload. Transfusion-associated circulatory overload can occur when a blood product is infused too quickly, especially in an older adult. This is most common with whole-blood transfusions or when the patient received multiple packed red blood cell transfusions. Symptoms include: hypertension, bounding pulse, distended jugular veins, dyspnea, restlessness and confusion.

A nurse is caring for a child who will be started on heparin therapy. Which assessment is a priority for the nurse to make before initiating this therapy? A Weight Correct Answer (Blank) B Lung sounds C Vital signs D Skin turgor

Rationale: The dosage of anticoagulant therapy in children is calculated on the basis of weight (weight-based calculation).

The nurse is evaluating the effectiveness of therapy for a client who received albuterol via nebulizer during an acute episode of shortness of breath due to asthma. Which finding is the best indicator that the therapy was effective? A Oxygen saturation is greater than 90% Correct Answer (Blank) B No wheezes are audible. C Respiratory rate is 16 breaths/minute. D Accessory muscle use has decreased.

Rationale: The goal for treatment of an asthma attack is to relieve bronchospasms and keep the oxygen saturation greater than 90%. Albuterol is a short-acting inhaled beta2-adrenergic agonist and the treatment of choice for an acute asthma attack. Pulse oximetry is an objective data point that the nurse should use to determine oxygenation status of the client. The other client data may occur when the client is too fatigued to continue with the increased work of breathing required in an asthma attack and, therefore, should not be used to evaluate effectiveness of treatment.

A nurse has asked a second nurse to sign for a wasted narcotic. The waste was not witnessed by the second nurse. What is the appropriate initial action? A Report the situation immediately to the nurse manager or nursing supervisor Correct Answer (Blank) B Counsel the colleague about this risky behavior C Confront the nurse about suspected drug use D Sign the narcotic sheet then document the event in an incident report

Rationale: The incident must be reported to either the unit nurse manager or, if not available, the nursing supervisor on duty. It is not the responsibility of the nurse to determine how or why the event occurred nor to conduct any sort of confrontation or counseling. Not having witnessed the waste then signing the narcotic sheet is a breach of protocol and policy. While an incident report should be completed, it does not directly address the issue at hand.

The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which point should the nurse emphasize? A Carry the nitroglycerine with you at all times Correct Answer (Blank) B Take the medication at the same time each day C Rest in bed for an hour after taking medication D Keep the medication bottle in the refrigerator

Rationale: The medication should be kept in its original dark-colored glass container. Nitroglycerin should be carried by the client at all times, so it can be used when anginal pain occurs. When needed, the client should sit and place a tablet under his or her tongue. Sitting is safe because the drug can cause lightheadedness or dizziness, but it's not necessary to rest in bed. The client should never pack this and any other medications in a checked bag when traveling.

The nurse is evaluating a client's adherence to the prescribed regimen of antihypertensive medications. Which finding is most indicative of effective hypertension management? A There is no indication of lower extremity edema. B There is no indication of renal impairment. Correct Answer (Blank) C The client's weight has been stable for the past two weeks. D The client's blood pressure reading is 148/94 mmHg.

Rationale: The most common complications of hypertension (HTN) are target organ diseases including of the kidneys. Uncontrolled HTN is the most significant risk factor for the development of chronic kidney disease. Therefore, the absence of renal impairment is a good indicator that the client is adhering to the prescribed medication regimen. A blood pressure of 148/94 is higher than recommended and indicates that the medication regimen may need to be adjusted. A stable weight and absence of edema are indicators often used to evaluate the management of heart failure, not HTN.

A 4-month-old infant is receiving digoxin. The infant's blood pressure is 92/78 mm Hg; resting pulse is 78 beats per minute; respirations are 28 breaths per minute; and serum potassium level is 4.8 mEq/L. The infant is irritable and has vomited twice since receiving the morning dose of digoxin. Which finding is most indicative of digoxin toxicity? Vomiting B Irritability C Bradycardia Correct Answer (Blank) D Dyspnea

Rationale: The most common sign of digoxin toxicity in children is bradycardia which is a heart rate below 100 beats per minute in an infant. Normal resting heart rate for infants 1-11 months-old is 100-160 beats per minute.

The nurse is caring for a client newly diagnosed with generalized anxiety disorder (GAD) who has been prescribed alprazolam by the health care provider (HCP). Which of the following statements best describes this medication in the treatment of GAD? A Alprazolam provides short-term treatment but is less effective than other drug therapy. Correct Answer (Blank) B There is no risk for developing a dependency to alprazolam. C Alprazolam will become more effective over time. D Alprazolam is the only recommended drug for GAD.

Rationale: The most effective pharmacological treatment for generalized anxiety disorder is considered to be SSRI or SNRI therapy. Benzodiazepines like alprazolam may be used for fast-acting pharmacological treatment. However, SSRIs or SNRIs are considered to be more effective than benzodiazepines. Clients can develop a chemical dependency to benzodiazepines, and these medications can become less effective over time because clients can develop a tolerance to its therapeutic effect.

A client is being discharged with a prescription for warfarin. Which information is most important to be included in the nurse's discharge teaching? A Use a soft toothbrush B Take acetaminophen for minor pain C Report nose or gum bleeding Correct Answer (Blank) D Avoid eating leafy green vegetables

Rationale: The most important teaching is to make sure that the client understands to report any sign of bleeding, including nose or gum bleeding, blood noted in stools or urine, coughing up blood, or easy bruising. Dark green leafy vegetables are high in vitamin K which can lower the effectiveness of warfarin (Coumadin). Acetaminophen does not contain aspirin, which can cause internal bleeding so is safe to use when taking warfarin. A soft toothbrush will be less irritating to the gums and therefore decrease the risk of bleeding gums. Although green leafy vegetables contain vitamin K, it is no longer recommended to avoid them but to keep their intake consistent.

A client with severe iron-deficiency anemia is prescribed a parenteral form of iron (i.e., iron dextran). Which intervention does the nurse prepare to implement before administering the medication? A Administer a small test dose. Correct Answer (Blank) B Obtain informed consent. C Obtain the client's vital signs. D Use the Z-track administration method.

Rationale: The most serious adverse effect of iron dextran is an anaphylactic reaction. Although anaphylactic reactions are rare, their possibility demands that iron dextran be used only when clearly required. To reduce this risk, each dose must be preceded by a small test dose and the client must be closely monitored while receiving the test dose. The nurse should be aware that even the test dose can trigger anaphylactic and other hypersensitivity reactions. In addition, even when the test dose is uneventful, patients can still experience anaphylaxis. The medication does not require informed consent and obtaining the client's vital signs does not prevent an anaphylactic reaction. If the medication is ordered to be administered intramuscularly, the Z-track technique should be used to minimize discomfort, leakage and surface discoloration.

The nurse is caring for a client with osteomyelitis who is receiving IV infusion of prescribed vancomycin. Which statement by the client would be a priority for the nurse to report to the healthcare provider? A "I fell some burning at the catheter site." B "I feel a little nauseous." C "I have a ringing in my ears." Correct Answer (Blank) D "I have a headache."

Rationale: The nurse who is caring for a client with osteomyelitis who is receiving IV infusion of vancomycin should assess the client for toxicity. The client who reports ringing in the ear could be experiencing ototoxicity, which is an adverse effect of vancomycin and should be reported to the healthcare provider. Headache, nausea, and burning at the IV site are side effects of the medication but not a priority for the nurse to report to the healthcare provider.

A 48-year-old male client who is being admitted to the emergency department with an acute myocardial infarction (MI) gives the following list of medications to the nurse. Which medication would the nurse recognize as having the most immediate implications for the client's care? A Captopril B Furosemide C Sildenafil Correct Answer (Blank) D Losartan

Rationale: The nurse will need to avoid giving nitrates to the client because nitrate administration, commonly prescribed for clients experiencing an acute MI, is contraindicated in clients who are using sildenafil (a PDE5 inhibitor) because of the risk of severe hypotension caused by vasodilation. The other medications the client is taking should also be documented and reported to the health care provider (HCP) but do not have as immediate an impact on decisions about the client's treatment.

The nurse is caring for a 1-year-old child after heart surgery. The child weighs 22 pounds (10 kg). The health care provider has given an order for morphine sulfate 4 mg IV every 3 to 4 hours as needed for pain. What should the nurse do next? A Give half of the dose first, wait 30 minutes, then give the other half B Check with the pharmacist to clarify the dose. C Verify that the dose is appropriate for this child. Correct Answer (Blank) D Administer the prescribed dose as ordered.

Rationale: The nurse's responsibilities for safe medication administration include knowledge of appropriate doses for pediatric clients and how to perform weight-based dosage calculations. Morphine prescribed parenterally (SQ/IM/IV), the recommended pediatric dose is 0.1 to 0.2 mg/kg (1 to 2 mg in this case) every 2 to 4 hours. Therefore, the prescribed dose falls outside of those guidelines (too high) and the nurse should clarify the prescription with the health care provider.

At the client's request, the nurse performs a fingerstick to test the client's blood glucose and the results are 322 mg/dL. Following the insulin sliding scale orders, the nurse administers 3 units of insulin lispro at 11:00 AM. When does the nurse anticipate the insulin lispro will begin to act? A 3:00 pm B 1:00 pm C 12:00 PM D 11:15 am

Rationale: The onset of action for insulin lispro, which is a rapid acting insulin, is 10 to 15 minutes after administration. It was administered at 11:00 AM, so it will begin to act at 11:15 AM.

The nurse is teaching a school-aged child and family members about the use of inhalers prescribed for asthma. Which statement made by a family member indicates an understanding of the nurse's instructions? A "Skin color changes in our child are an early warning sign for airway constriction." B "Monitoring our child's pulse rate is not necessary." C "We will keep a chart of daily peak flow meter results." Correct Answer (Blank) D "We can rely on our child's self-report of symptoms."

Rationale: The peak flow meter can help determine if the symptoms of asthma are in control or are worsening. It works by measuring how fast air comes out of the lungs when the client forcefully exhales (the peak expiatory flow or PEF). The client should record the highest of three readings in an asthma diary daily. Children ages 4 and up should be able to use a peak flow meter. A decrease in PEF is an early warning sign for airway constriction and should be immediately addressed. Family members should monitor the child's pulse rate, and changes in skin color are a late sign.

A client has been diagnosed with hypothyroidism. Which medication should the nurse administer to treat the client's bradycardia? A Adenosine B Epinephrine C Levothyroxine Correct Answer (Blank) D Atropine

Rationale: The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using levothyroxine sodium, a T4 replacement hormone. If the heart rate were so slow that it causes hemodynamic instability, then atropine or epinephrine might be an option for short-term management. Adenosine slows atrioventricular (AV) conduction in the heart and would be contraindicated for a client with bradycardia

The nurse is caring for a client who is prescribed warfarin. Which lab test would the nurse monitor to determine a therapeutic response to the drug? A International Normalized Ratio (INR) Correct Answer (Blank) B Partial thromboplastin time (PTT) C D-dimer D Bleeding time

Rationale: The warfarin dosage is based on the result of a client's daily INR (or prothrombin time [PT]). Warfarin affects the function of the coagulation cascade and inhibits the formation of blood clots. The goal of warfarin therapy is to maintain a balance between preventing clots and causing excessive bleeding, which is why careful monitoring is needed. A Partial thromboplastin time (PTT) is associated with monitoring heparin. A bleeding time test is performed to monitor basic platelet function. The d-dimer test is a test used to diagnose a blood clot.

A client who had surgery is discharged on warfarin. Which statement by the client is incorrect and indicates a need for further teaching? A "I will keep all laboratory appointments." B "I will report any bruises or unusual bleeding." C "I know I must avoid crowds." Correct Answer (Blank) D "I plan on using an electric razor for shaving."

Rationale: There are no specific reasons for the client on warfarin to avoid crowds. Clients should not use a straight edge razor, should report any unusual bleeding and must keep all laboratory appointments when taking the blood thinner warfarin.

The nurse is providing discharge education to a client newly diagnosed with chronic obstructive pulmonary disease. The client is prescribed the Diskus inhaler Advair (fluticasone propionate and salmeterol). The client asks, "How will I know when the inhaler is empty?" How should the nurse respond? A Shake the canister to detect any fluid movement B The number of doses that remain will be on the inhaler Correct Answer (Blank) C Estimate how many doses are usually in the canister D Drop the canister in water to observe floating

Rationale: There are several methods to monitor the contents of an inhaler. New MDIs such as Diskus inhalers often have counters on them. The counters record the number of doses left in the canister. If the MDI does not have this feature, the client should write the date a refill is needed. This can be done directly on the canister in a permanent marker. Manufacturers do not recommend floating inhalers. The shaking or estimation method will not be accurate.

The nurse is caring for a client who is receiving a blood transfusion. The client develops urticaria 30 minutes after the transfusion began. What is the first action the the nurse should take? A Take vital signs and observe for further deterioration B Stop the infusion Correct Answer (Blank) C Administer Benadryl and continue the infusion D Slow the rate of infusion

Rationale: This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion by disconnecting at the IV insertion site. The nurse should then start a saline line at the IV insertion site and notify the health care provider.

A client diagnosed with bipolar disorder is reluctant to take lithium as prescribed. Which response should the nurse make in this situation? A "If you refuse your medicine, we'll just have to give you a shot." B "What is it about the medicine that you don't like or are concerned about?" Correct Answer (Blank) C "I can see that you are uncomfortable right now. I'll wait until tomorrow to discuss this with you." D "You need to take your medicine. This is how you will get well."

Rationale: This response validates the client's feelings and is exploring concerns. It should generate therapeutic dialogue between the client and nurse. It provides an opportunity for the nurse to teach the client about lithium. Telling the client an injection will be given is coercive and incorrect since lithium does not come in an injectable form, and the client's behavior does not indicate aggression or need for another as-needed medication. Waiting until tomorrow is not a viable option as the client does need to take this medication, which needs to reach a therapeutic serum level. Advising the client to take the medication in order to get well is vague and does not validate feelings or explore concerns.

The nurse is discharging a client with a new prescription for tiotropium to help manage the symptoms of chronic obstructive pulmonary disease. What information should the nurse include in the discharge teaching? A A common side effect is nausea and loose stools. B It may be a few days before you feel the full effects of tiotropium. C This medication cannot be used to relieve sudden breathing problems. Correct Answer (Blank) D Be sure to swallow the capsules with a full glass of water.

Rationale: Tiotropium is a long-acting anticholinergic bronchodilator. The medication comes as a capsule to use with a specially designed inhaler - clients should never swallow the capsules. For new prescriptions, it's important to tell the client that they may start breathing better with the full dose but it may take a few weeks to feel the full effects. It cannot be used as a fast-acting inhaler. Due to its anticholinergic properties, it may cause constipation (not loose stools).

A hospitalized infant is receiving gentamicin. While monitoring for drug toxicity, the nurse should focus on which laboratory result? A Serum creatinine Correct Answer (Blank) B Growth hormone levels C Thyroxin levels D Platelet counts

Rationale: Toxicity to the aminoglycoside antibiotic gentamicin is seen in increased BUN and serum creatinine levels. Kidney damage may be reversible if the drug is stopped at the first sign of toxicity. In addition to nephrotoxicity, this medication has a Black Box warning for neurotoxicity and ototoxicity.

A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections. Which information should the nurse include during client teaching? A "Drink at least eight large glasses of water a day." Correct Answer (Blank) B "Stop the medication when your symptoms disappear." C "A harmless skin rash may appear." D Be sure to take the medication with food."

Rationale: Trimethoprim/sulfamethoxazole (Bactrim) is a highly insoluble drug that can cause crystalluria, and clients should drink plenty of fluids while taking this medication to lower the risk of developing kidney stones. Increased fluid intake is also recommended with a UTI to promote the "flushing out" of bacteria. The drug may be taken with or without food. Clients should take the medication for the prescribed length of time. Sulfonamide-containing products should be discontinued at the first appearance of skin rash. In rare instances, a skin rash may be followed by a more severe reaction, such as Stevens-Johnson syndrome or toxic epidermal necrolysis.

A nurse is teaching an 80-year-old client how to use a metered dose inhaler. The nurse is concerned that the client is unable to coordinate the release of the medication during the inhalation phase. Which intervention should improve the delivery of the medication? A Request a home health nurse to visit the client at home. B Ask a family member to assist the client with the inhaler. C Add a spacer device to the inhaler canister. Correct Answer (Blank) D Use nebulized treatments at home instead.

Rationale: Use of a spacer is especially useful with older adults because it allows more time to inhale and requires less eye-hand coordination. If the client is not using the metered dose inhaler (MDI) properly, the medication can get trapped in the upper airway and lead to dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth.

A client who was prescribed sertraline to treat depression informs the nurse that they stopped taking the sertraline and began taking their partner's tranylcypromine. The client reports experiencing "muscle twitches" and a "racing heart rate". Which adverse reaction should the nurse immediately assess for? A Mental status changes Correct Answer (Blank) B Atrial fibrillation C Muscle weakness D Pulmonary edema

Rationale: Use of serotonergic agents may result in serotonin syndrome with confusion, nausea, palpitations, increased muscle tone with twitching muscles, and agitation. Serotonin syndrome is most often reported in clients taking two or more medications that increase CNS serotonin levels by different mechanisms. The most common drug combinations associated with serotonin syndrome involve MAOIs, SSRIs, and tricyclic antidepressants.

The nurse is planning to administer a series of vaccines to a 4-year-old child including the DTap, IPV, MMR, and VAR. Before administering the vaccines, what information should the nurse be aware of? Select all that apply. A A 5/8 inch needle length is often used for subcutaneous (SubQ) injections Correct Answer (Blank) B The vaccines all contain weakened live viruses C Either the deltoid muscle of the arm or anterolateral thigh muscle can be used Correct Answer (Blank) D A 20 gauge needle is used to administer the varicella (VAR) vaccine intramuscularly (IM) E Multiple immunizations should be administered a minimum of 1 inch apart Correct Answer (Blank) F The vaccines contain the preservative thimerosal

Rationale: Vaccinations for a 4 to 6 year-old child include diphtheria, tetanus, and whooping cough (DTaP), Polio (IPV), measles, mumps, and rubella (MMR), and chicken pox (Varicella). DTap is given intramuscularly (IM) and can be administered in either the deltoid muscle of the arm or the anterolateral thigh muscle. The IPV can be administered either subcutaneously (subq) or IM. If multiple vaccinations are to be administered, injections should be spaced a minimum of 1-inch apart. The MMR and Varicella are administered subq using a 5/8 inch, 25-gauge needle. Not all the vaccinations contain live viruses; IPV and DTaP. Vaccines no longer contain thimerosal, which is a form of mercury.

A client with major depression is prescribed the extended release form of venlafaxine. Which statement by the client indicates a need for additional teaching? A "I should swallow the pill whole." B "I may feel nauseated and anorexic." C "I can stop taking the drug when I start feeling better." Correct Answer (Blank) D "I will call my doctor if I experience impotence."

Rationale: Venlafaxine is a serotonin/norepinephrine reuptake inhibitor (SNRI) used for major depression, panic disorders and social phobias. It blocks neuronal uptake of serotonin and norepinephrine with minimal effects on other transmitters or receptors. Pharmacologic effects are similar to those of SSRIs. The most common side effect is nausea (37% to 58%). Sexual dysfunction may occur and can cause the client to stop taking the medication. Therefore, the client should contact their provider for a possible alternate prescription. The client is prescribed the extended release form and should not chew or break the pill, but swallow the pill whole. The client is expected to feel less depressed and should not stop taking the medication. Abrupt discontinuation can cause an intense withdrawal syndrome. Symptoms include anxiety, agitation, tremors, headache, vertigo, nausea, tachycardia and tinnitus. Worsening of pretreatment symptoms may also occur.

The nurse is reinforcing medication interactions with a client who is taking warfarin. Which over-the-counter (OTC) medication should the nurse remind the client to avoid? A Pantoprazole B Naproxen Correct Answer (Blank) C Acetaminophen D Diphenhydramine

Rationale: Warfarin is an anticoagulant. OTC medications that interact with warfarin should be avoided. Naproxen, a nonsteroidal anti-inflammatory drug (NSAID), is a commonly used OTC analgesic. Naproxen can prolong bleeding time and should therefore be avoided by clients who take anticoagulants. The other medications are not contraindicated when taking warfarin.

The nurse is preparing to administer blood products as a part of fluid resuscitation to a client in shock. The nurse understands which of the following is necessary prior to the administration of the blood products? A Placement of a foley catheter to monitor output B Placement of 2 large bore IV's Correct Answer (Blank) C Baseline lung assessment D Suction equipment at the bedside

Rationale: When a client is in hypovolemic shock, multiple fluids need to be administered at one time. Prior to giving blood, the nurse should ensure that two large bore IVs are in place in order to ensure the blood products can be administered prior to them expiring. The baseline lung assessment should be done but is not in relation to the fluid being administered. The Foley catheter should be in place prior to administering any fluid, not just blood. Suction equipment is not required.

The nurse is admitting a client from a long-term care facility who has a history of dementia. When obtaining the client's medication records, which action would be most appropriate? A Request a copy of the client's medication list from the long-term facility Correct Answer (Blank) B Call the healthcare provider for a verbal report of the medication list C Instruct a family member to bring a medication list D Review the client's medical records for a previous medication list

Rationale: When admitting a client with a history of dementia, the nurse will have to use resources to obtain a current health history, including the list of current medications. The most appropriate action would be to request that the long-term care facility provide a copy of the client's current medication list. Requesting a verbal report from the healthcare provider could result in inaccurate information. Reviewing the client's medical record may not provide the most current medication list. Instructing the family to bring a list may not be as accurate.

The nurse is preparing to start a peripheral venous access device on an alert and oriented adult client. Which supplies should the nurse select? Select all that apply. Adhesive tape Correct Answer (Blank) An arm board Transparent dressing Correct Answer (Blank) Soft wrist restraint An appropriate size IV catheter Correct Answer (Blank) Antiseptic skin swab Correct Answer (Blank) Saline flush syringe Correct Answer (Blank)

Rationale: When preparing to start a peripheral venous access device, the nurse should select a catheter that is appropriate in size for the client and medication or IV fluid administration. Most facilities provide "IV start kits" that contain the necessary supplies including a transparent dressing, adhesive tape and an antiseptic skin swab. A soft wrist restraint or arm board which can be considered a "restraint" if it limits movement, are not indicated for this client.

The nurse is reinforcing teaching to a 24-year-old woman receiving acyclovir for a herpes simplex virus type 2 infection. Which instructions should the nurse provide the client with? A Stop treatment if she thinks she may be pregnant B Complete the entire course of the medication for an effective cure C Begin treatment with acyclovir at the onset of symptoms of recurrence Correct Answer (Blank) D Continue to take prophylactic doses for at least five years after the diagnosis

Rationale: When the client is aware of early symptoms, such as pain, itching, or tingling, treatment is very effective. Medications for herpes simplex do not cure the disease. They simply decrease the intensity of the symptoms. Acyclovir (Zovirax) is not known to have an impact on the fetus. Acyclovir should not be taken for preventive purposes regardless of the date of diagnosis.

The nurse is to administer erythromycin ethyl succinate 280 mg. The supply available is 400 mg/5 ml. How many ml would the nurse administer with each dose?

Rationale: ml/dose = (5 ml / 400 mg) x (280 mg/dose) = 1,400 / 400 = 3.5

The nurse is preparing to administer levothyroxine 125 mcg to a client. The available supply is 50 mcg levothyroxine. How many tablets should the nurse administer to the client?

Rationale: tablets/dose = (1 tab / 50 mcg) x (125 mcg/dose) = 125 / 50 = 2.5

The nurse is caring for a client with pulmonary embolism that is to receive prescribed heparin 25,000 units in 250 ml of normal saline continuous infusion at 15 ml/hr. How many units per hour will the nurse administer to the client?

Rationale: units/hr = (25,000 units / 250 ml) x (15 ml/hr) = 375,000 / 250 = 1,500

A nurse is providing care to a client with diabetes insipidus. The client is on a prescribed vasopressin infusion with orders to titrate as needed. The nurse decreases the dose of vasopressin based on which clinical finding? Increased blood pressure Decreased urine osmolarity Reduced volume of urine output Elevated heart rate

Reduced volume of urine output Rationale: Diabetes insipidus is an endocrine disorder that causes the excretion of large quantities of diluted urine. Vasopressin decreases urine output by allowing the reabsorption of water in the kidneys. A reduction in the volume of urine output indicates the medication is delivering the intended effect, and the dose can be decreased. Vasopressin can increase blood pressure and heart rate. However, these are not the intended effects of vasopressin for a client with diabetes insipidus. A decrease in the urine osmolarity indicates dilution is still present.

The nurse is caring for a client diagnosed with diabetic ketoacidosis who is receiving 50 mEq of sodium bicarbonate in 1 L of dextrose 5% in water via a central venous access device. The client has three new prescriptions for continuously infused medications. Which action is appropriate? Refer to an IV compatibility chart Request that an additional IV access be inserted Use a Y-site connector to infuse two medications in the same port Insert a peripheral intravenous access

Refer to an IV compatibility chart Rationale: Sodium bicarbonate is incompatible with many other drugs and solutions. The nurse should consult a drug compatibility reference for more information on which drugs can be administered via connection at the most distal IV tubing port. Y tubing should not be added to an IV until compatibility is determined. Y tubing does not prevent the mixing of infusions. Adding an additional access may be unnecessary if compatibility is determined and may pose an unnecessary infection risk to the client. A central line is the preferred access for drugs that have a pH less than 5 and greater than 9. Certain drugs are venous irritants regardless of pH or concentration; therefore, a PIV would be inappropriate.

The nurse is obtaining vital signs on a stable client using an electronic blood pressure cuff. The cuff begins to inflate, but the machine is making an unusual sound. The client states that it is painfully tight. Which of the following actions is appropriate? Remove the cuff from the client and take note of which device is defective Remove the device from service and call biomedical services to provide maintenance Obtain the blood pressure with the device and then report the issue to the charge nurse Ask another nurse to assist in troubleshooting the device and obtain the blood pressure

Remove the device from service and call biomedical services to provide maintenance Rationale: Obtaining accurate vital signs is essential to quality nursing care. When a BP machine is not operating correctly, the data it provides may not be reliable and there is a risk of harm to the client if any intervention is based on an inaccurate BP. The device should be removed from service until it can be checked for accuracy and safety and, if needed, repaired.

The nurse is preparing to administer a medication via a transdermal patch to a client. Which action by the nurse is appropriate? Apply lotion to the skin prior to placement Utilize heat therapy over top of the patch after placement Remove the previous patch prior to placement Apply the patch in the same location as the previous placement

Remove the previous patch prior to placement Rationale: Any previous medication patches should be removed prior to placing the new transdermal patch to ensure that the client receives the correct dose. Heat and cold therapy should be avoided at the patch location as temperature may affect the absorption rate. The skin should be clean and dry before application, and sites should be rotated to decrease the risk of skin breakdown.

A nurse is reviewing a client's medical history. The client has been newly diagnosed with hypertension and has been prescribed oral losartan as treatment. The nurse will clarify the use of losartan if which comorbidity is noted in the client's medical record? Renal stenosis Hyperlipidemia Atrial fibrillation Diabetes

Renal stenosis Rationale: Losartan is an angiotensin II receptor blocker used in the treatment of hypertension. Losartan is contraindicated in clients with renal stenosis due to the risk of kidney injury. Hyperlipidemia, atrial fibrillation, and diabetes are not known to be contraindicated in the use of losartan.

The nurse is preparing to administer trimethoprim and sulfamethoxazole (TMP-SMX) to a client. When assessing client allergies, the client reports that they are allergic to glipizide. What action by the nurse is most appropriate? Prepare to administer the medication Report the allergies to the healthcare provider Review the health record to see if the client is on glipizide Assess the client's blood sugar

Report the allergies to the healthcare provider Rationale: While administering a sulfonamide with a sulfonylurea may increase the risk of a hypoglycemic reaction, the real concern is the potential allergy to TMP-SMX. It may be safe to administer the medication, but the healthcare provider should be notified first.

A nurse has removed a 2 ml vial of fentanyl from the medication dispensing system. After dosage calculations, the nurse determines only 1 ml will be administered to the client. Which action will the nurse perform with the remainder of the medication? Request another nurse to witness wasting of the unused medication Dispose of the unused medication in the sink Store the unused of the medication in the medication cart Return the unused medication to the dispensing system

Request another nurse to witness wasting of the unused medication Rationale: Unused controlled substances such as fentanyl should be wasted. The waste of narcotics requires a witness. The nurse should request another licensed nurse to witness the waste of the additional 1 ml of medication. Disposal of controlled substances should be witnessed. Unused controlled substances should be wasted, not stored or returned to the dispensing system.

The nurse is reviewing the medical record of a client with bipolar disorder. The client is prescribed aripiprazole (Abilify) 10 mg once a day but reports that they have not taken the medication in several weeks. Which action should the nurse take? A Instruct the client's partner to make sure the medication is taken every day. B Inform the client that they will have to be admitted to an inpatient psychiatric facility. C Educate the client on the importance of taking their medications as prescribed. D Request for the medication to be changed to a once monthly injection.

Request for the medication to be changed to a once monthly injection. Rationale: Aripiprazole (Abilify) is the first representative of a unique class of antipsychotic drugs, referred to as dopamine system stabilizers (DSSs). Approved indications are schizophrenia, acute bipolar mania, major depressive disorder, agitation associated with schizophrenia or bipolar mania. Aripiprazole is available in standard tablets, orally disintegrating tablets and extended-release injections that can be given monthly. For clients who struggle with adherence, a once a month injection is a good alternative to a daily oral dose. The other actions are not appropriate, helpful or necessary.

The nurse is caring for a client with acute pain and realizes a medication error has occurred. The client received twice the ordered dose of morphine an hour ago. Which nursing problem is the priority at this time? A Chronic pain B Constipation C Tolerance D Respiratory depression

Respiratory depression Rationale: Opioids (e.g., morphine) are indicated for the treatment of moderate to severe pain. An opioid is a medication that relieves pain by binding to receptors in the nervous system. Respiratory depression is a life-threatening risk in an opioid overdose. The priority problem is ineffective respirations/respiratory depression due to central nervous system depression.

A nurse is preparing to administer morphine to a client with chronic pain. Which assessment finding would prompt the nurse to withhold the medication? Heart rate of 117 beats/min Urine output of 35 ml/hr Oxygen saturation of 92% Respiratory rate of 11 breaths/min

Respiratory rate of 11 breaths/min Rationale: The nurse should withhold the medication if the respiratory rate is 11 breaths/min. Opioid medications, such as morphine, can cause respiratory depression. A respiratory rate of 11 breaths/min increases the risk of respiratory depression and arrest. The normal respiratory rate is 12-20 breaths/min. A heart rate of 117 beats/min (tachycardia) is not contraindicated with the use of morphine. Morphine can cause the opposite effect, bradycardia. Morphine can cause urinary retention; however, a urine output of 35 ml/hr is a normal finding. Oxygen saturation of 92% is a low-normal finding. The nurse should administer the medication and monitor the client's respiratory status.

The nurse is collecting the health history for a client who reports a sudden onset of generalized weakness and fatigue. The nurse notes the client has a new prescription for spironolactone. Which action should the nurse take first? Review the drug formulary for side effects Request the health care provider to stop the medication Notify the pharmacist of the findings Document the findings

Review the drug formulary for side effects Rationale: During medication administration, it is important for the nurse to assess knowledge of drugs, including adverse effects and physiologic factors that affect drug action. Information about specific drugs is available in pharmacology texts and drug reference books. Calling the health care provider may be an option after reviewing the drug formulary. The nurse should notify the pharmacist if the medication is the cause of the symptoms. The nurse will document the findings, but the priority is to review the formulary.

The nurse is assessing a client with hypertension who reports experiencing dizziness after taking prescribed diltiazem. It is most important that the nurse assesses for which client characteristic? A Activity and rest patterns B Daily intake of potassium C Appearance of feet and ankles D Schedule for taking medication

Schedule for taking medication Rationale: A critical focus is whether the client has complied with the prescribed medication schedule and dose. Although diltiazem (Cardizem, Cartia, Dilacor, Diltia, Taztia, Tiazac) can be taken either in the morning or evening, taking the medication in the evening might help with this common side effect.

The nurse is caring for the client receiving total parenteral nutrition. Which of the following findings indicates that the treatment is therapeutic? Blood glucose level of 160 mg/dl Serum albumin level of 3.6 g/dl Serum bilirubin level of 1.3 mg/dl Hemoglobin level of 10 g/dl

Serum albumin level of 3.6 g/dl Rationale: The goal of total parenteral nutrition (TPN) is to increase serum total protein and serum albumin concentrations and improve nitrogen balance. Unintended effects include hyperglycemia and liver dysfunction (elevated bilirubin levels). This client is demonstrating a low hemoglobin level, which is not a result of TPN.

The nurse is preparing to administer the next dose of prescribed vancomycin to the client being treated for sepsis. Which of the following laboratory results would be the priority for the nurse to review? Peak serum drug level Serum potassium level Serum creatinine level White blood cell count

Serum creatinine level Rationale: Vancomycin can lead to interstitial nephritis and therefore, serum creatinine should be monitored. Prior to a dose, a trough level would be drawn to help assess minimum inhibitory concentration; however, peak levels are not needed for this purpose and are drawn after administration. Do not hold the next vancomycin doses while waiting for the results of vancomycin levels unless there is a concern about renal function. Therefore, the priority is serum creatinine. While the treatment of infection is the goal, assessing white blood count (WBC) prior to administration is not necessary.

The nurse is assessing a client with suspected aspirin overdose. Which assessment findings would support this diagnosis? Select all that apply. Jaundice Serum pH 7.31 Correct Answer (Blank) Tinnitus Correct Answer (Blank) Headache Correct Answer (Blank) Hypoglycemia Respiratory rate of 28

Serum pH 7.31 Tinnitus Headache Respiratory rate of 28 Rationale: Aspirin belongs to a chemical family known as salicylates. All members of this group are derivatives of salicylic acid. Aspirin is produced by substituting an acetyl group onto salicylic acid and is commonly known as acetylsalicylic acid, or simply ASA. Low therapeutic doses of aspirin produce plasma salicylate levels less than 100 mcg/ mL. Anti-inflammatory doses produce salicylate levels of about 150- 300 mcg/ mL. Signs of salicylism (toxicity) begin when plasma salicylate levels exceed 200 mcg/ mL. Severe toxicity occurs at levels above 400 mcg/ mL. Salicylism is a syndrome that begins to develop when aspirin levels climb just slightly above therapeutic. Overt signs include tinnitus (ringing in the ears), sweating, headache, and dizziness. Acid-base disturbance (metabolic acidosis) may also occur. The respiratory rate will increase in an effort to 'blow off' CO2 to compensate for the acidosis. Hypoglycemia and jaundice are not typically seen with salicylate overdose.

The nurse is teaching the parents of an infant client about protective measures to reduce injuries at home. Which of the following actions, if identified by the parent, indicates the need for further teaching? Placing covers over electrical outlets Using guard gates on stairs and windows Setting the water heater maximum temperature to 140°F Maintaining the crib slats no greater than 2.5 inches apart

Setting the water heater maximum temperature to 140°F Rationale: It requires further teaching if the parent states that the water temperature maximum should be set at 140°F. It is recommended that the temperature maximum be set at 120°F to minimize the risk of scalding burns during baths. It is the correct understanding of protective measures to place covers over electrical outlets to reduce risk of electrical shock, to use guard gates on stairs and windows to reduce risk of falling, and to maintain crib slats no greater than 2.5 inches apart.

The nurse is providing discharge education to a client who is prescribed alprazolam for a panic disorder. What concept should the nurse emphasize concerning the drug action? A The medication acts as a stimulant B The medication works by suppressing dopamine C If you miss a dose, double the next scheduled dose D Short-term relief can be expected

Short-term relief can be expected Rationale: Alprazolam is a short-acting benzodiazepine, which works quickly to control panic symptoms by enhancing the effects of the neurotransmitter Gamma-amino butyric acid (GABA). This produces a calming effect. The drug does not suppress dopamine like dopamine antagonists and some antipsychotic medications. Alprazolam will not be increased as tolerated, the lowest dose that controls the symptoms will be maintained.

The nurse is preparing a client who is non-verbal for a lumbar puncture. The nurse instructs the client to remain still during the procedure. Which information should the nurse provide to the client on how to communicate with staff during the procedure? Shake their head back and forth Raise hand above head Squeeze the nurse's hand Use a finger to tap on the bed

Squeeze the nurse's hand Rationale: Clients are instructed not to move during the procedure. Any movement can cause the needle to shift. The nurse helps keep the client in the proper alignment and provides support. Squeezing the nurse's hand requires little movement by the client; the other methods require significant movement.

A client who is receiving a blood transfusion suddenly reports having a severe headache and lower back pain. Which actions should the nurse take? Select all that apply. Stop the blood transfusion Flush the IV line with 30 mL of normal saline Obtain a urine specimen as soon as possible Complete an incident/occurrence report Notify the rapid response team Provide emotional support to the client

Stop the blood transfusion Obtain a urine specimen as soon as possible Complete an incident/occurrence report Provide emotional support to the client Rationale: Clients who are receiving a blood transfusion can develop any one of these transfusion reactions: febrile, hemolytic, allergic or bacterial reactions, circulatory overload, or transfusion-associated graft-versus-host disease (TA-GVHD). The client in this scenario appears to be experiencing a hemolytic reaction, which is caused by blood type or Rh incompatibility. Interventions for this type of reaction should include immediately stopping the transfusion and removing the blood tubing. The nurse should not flush the contents of the blood transfusion tubing, which would allow more of the reaction-causing blood to enter the client. Instead, a second, new IV access is preferred, especially for the fluid resuscitation the client will most likely require. Because of the high risk of kidney failure with this type of reaction, a urine sample is collected. This situation will also require an incident report to be completed, and the blood bank needs to receive all of the original blood product and tubing for analysis and to figure out how this reaction happened. The client might feel anxious and the nurse should provide emotional support. Notifying the rapid response team (RRT) is not indicated at this time.

A staff nurse is assisting a charge nurse with checking controlled substances at the change of shift. The charge nurse is urgently called to a client's room and has to leave the medication room. Which action will the staff nurse take? Continue performing the check while the charge nurse assists the client Leave the medication room to find another nurse to assist with the check Stop the check and sign out of the medication dispensing system Pause the check until the charge nurse returns to the medication room

Stop the check and sign out of the medication dispensing system Rationale: Performing inventory on controlled substances with another nurse should be finalized in one session. If one of the nurses is unable to complete the count, the session should be terminated, and the dispensing system should be secured. Performing an independently controlled substance check is not safe nursing practice. An open medication dispensing system should never be left unattended, especially with controlled substances. The charge nurse should not leave the medication room after entering credentials into the dispensing system. Both nurses should sign out of the system if unable to complete the check.

A nurse is assessing a client receiving alteplase for a pulmonary embolism. The client suddenly becomes confused and is unable to follow commands. What action does the nurse take first? Notify the healthcare provider Reorient the client Check the client's pupils Stop the infusion

Stop the infusion Rationale: Alteplase is a thrombolytic medication that causes lysis of blood clots. Alteplase is a high-risk medication that can cause internal bleeding. Sudden neurological deficits may indicate an intracranial bleed. The nurse should stop the infusion. Reorienting the client, checking the pupils, and notifying the healthcare provider are all necessary interventions after the infusion is stopped for safety.

The nurse is administering multiple infusions into single intravenous access. The nurse notes precipitates in the IV tubing. Which action is appropriate? Stop the infusion Slow the infusion rate Continue to monitor the infusion Change the tubing

Stop the infusion Rationale: Drug incompatibilities are chemical and physical reactions between drugs and/or with the carrier fluid during their IV administration through the same venous access. These incompatibilities can lead to precipitate formation. Particles administered to patients through IV infusion may lead to complications, as well as an increased risk of venous thromboembolism. Rare cases of fatal pulmonary embolism have even been reported. If precipitates are identified, infusions should be stopped immediately.

The nursing is preparing to administer phenytoin IV push to a client. The client has dextrose 5% in water infusing continuously. Which action is appropriate? Pinch the line above the infusion port during the administration Hold the medication and collaborate with the provider prior to administration Stop the infusion and flush the port with normal saline prior to administration Ask the pharmacy to mix the medication into an IV piggyback (IVPB) infusion

Stop the infusion and flush the port with normal saline prior to administration Rationale: If giving phenytoin as an infusion, it cannot be administered with D5W because it will precipitate. The D5W should be disconnected, the port flushed with normal saline solution (NSS), medication administered, and the port flushed again with NSS before the D5W is reconnected. The provider does not need to be contacted as this is best practice and aligns with hospital protocol. Administering the medication via IVPB does not reduce the risk for precipitation.

A client is being transfused with one unit of packed red blood cells. Within 15 minutes of the transfusion, the client reports having chills and a headache. Which action should the nurse take first? A Notify the health care provider B Obtain a set of vital signs C Obtain a urine specimen D Stop the transfusion

Stop the transfusion Rationale: The first action of the nurse should be to stop the blood transfusion. Based on the client's symptoms, they are having a hemolytic transfusion reaction. This could be caused by mismatched blood types. Most frequent symptoms include fever, chills, itching, hives, and a headache. It would be essential for the nurse to assess for this manifestations within the first 15 minutes of the transfusion, throughout, and 90 minutes after. After the nurse stops the infusion, the health care provider and the blood bank should be notified for further evaluation and treatment.

A nurse has initiated a blood transfusion on a client 15 minutes ago. As the nurse is assessing the client's response, the client states, "My lower back is starting to hurt, and I feel nauseous." Which action does the nurse take next? Slow the transfusion rate and administer an anti-emetic Continue the transfusion and offer the client an emesis basin Stop the transfusion and take the client's vital signs Pause the transfusion and administer pain medication

Stop the transfusion and take the client's vital signs Rationale: The client's symptoms are indicative of a transfusion reaction. The nurse should stop the transfusion and take the client's vital signs. Any abnormal findings should immediately be reported to the healthcare provider. Administering an anti-emetic will correct the nausea but it does not address the possibility of the client having a transfusion reaction. Continuing the transfusion may cause a further, serious reaction to the blood product. Administering pain medication will relieve the client's back pain but does not address the possible transfusion reaction.

A nurse is preparing to administer reconstituted doxorubicin (Myocet) to a client with thyroid carcinoma. Nuclear medicine calls for the client, and the nurse is unable to administer the medication. Which action should the nurse perform with the medication? Save the medication in a syringe with an aluminum needle Store the medication in the refrigerator inside the syringe Discard the medication in the hazardous waste container Add the medication to the intravenous fluids in the client's room

Store the medication in the refrigerator inside the syringe Rationale: Doxorubicin that is stored in a refrigerator is stable for up to 48 hours. The medication remains stable at room temperature for up to 24 hours. Saving the medication with an aluminum needle will cause discoloration of the solution and form a dark precipitate. Discarding the medication is not necessary. The medication can be stored for 24-48 hours. Doxorubicin should not be added to intravenous fluids. The medication should be dissolved completely with a diluent.

A nurse is preparing to administer a piggyback infusion to a client. The unlicensed assistive personnel (UAP) enters the room and informs the nurse another client is requesting immediate assistance. Which action will the nurse perform? Instruct the UAP to finish connecting the medication Continue to administer the medication to the client Leave the medication hanging on the client's IV pole Store the solution bag in the medication cart

Store the solution bag in the medication cart Rationale: Administering a piggyback infusion requires priming the tubing and setting up the infusion pump. This process can be lengthy, and the nurse is immediately needed in another room. The medication cart provides a safe storage environment for the medication. Administering intravenous medication is not a task that can be delegated to unlicensed assistive personnel. The nurse should prioritize client needs. A client requesting immediate assistance needs to be assessed first before administering a piggyback infusion to the current client. Unused medication should not be left unattended.

A nurse is preparing a medication for a client in the medication room. The nurse receives an emergency call while withdrawing medication into a syringe. Which action should the nurse take? Discard the medication from the syringe into the sink Place the syringe in the clothes pocket before leaving the medication room Store the syringe in the client's drawer in the medication cart Leave the syringe on the counter in the medication room

Store the syringe in the client's drawer in the medication cart Rationale: The nurse should store the syringe in the client's drawer in the medication cart. This action ensures the medication is secured and ready to administer after the nurse responds to the emergency call. Discarding the medication into the sink is not necessary. The medication can be stored in a secure location. Placing unlabeled medication in a clothes pocket is not safe nursing practice. Leaving the syringe on the counter in the medication room is not appropriate nursing practice. The medication is not labeled and can be diverted.

A nurse is preparing to administer total parenteral nutrition (TPN) to a client. The nurse knows that TPN should be administered through which access site? Antecubital peripheral line Brachial midline Subclavian central line External jugular peripheral line

Subclavian central line Rationale: Total parenteral nutrition (TPN) is a hypertonic, highly concentrated solution that should only be administered through a central venous access device. Administration through a peripheral line is not safe practice due to the density of the nutrition. A midline does not cross the axillary line and is considered a peripheral access.

A nurse receives a prescription to administer regular insulin U-500 to a client with diabetes mellitus. How will the nurse administer this medication? Intravenously using an infusion pump Subcutaneously using an insulin pump Intramuscularly using a U-100 syringe Subcutaneously using a U-500 syringe

Subcutaneously using a U-500 syringe Rationale: Insulin U-500 is a highly concentrated form of insulin that is five times stronger than regular insulin. This medication should only be administered subcutaneously with a specialized U-500 syringe for accurate measurement. Concentrated insulin should not be administered intravenously, intramuscularly, or via an insulin pump due to the high risk of hypoglycemic episodes.

The nurse is caring for a client after cardiac surgery who has been prescribed protamine sulfate. Which finding indicates that the treatment is having the intended effect? The international normalized ratio (INR) is trending down. The bleeding from the surgical site has slowed. The client reports decreased chest pain. The respiratory rate is increased.

The bleeding from the surgical site has slowed. Rationale: Protamine sulfate is the antidote for standard heparin and low molecular weight heparins (LMWHs). Protamine is typically given for bleeding that may not respond to merely withdrawing the heparin or when hemorrhaging is present. INR is used to determine the therapeutic level of warfarin, not coumadin. Chest pain would be treated with nitroglycerin but not protamine. The respiratory rate would be increased by naloxone if opiates were prescribed.

The nurse is preparing to administer prescribed warfarin to a client with a mechanical heart valve. Which finding should the nurse report to the healthcare provider? The INR is 3.0. The peripheral IV site has been oozing blood. The aPTT is 30. The client has cola-colored urine.

The client has cola-colored urine. Rationale: Cola-colored urine is a sign of hematuria. This may be caused by the warfarin or a sign of another problem. It is common to have oozing around IV sites in clients on anticoagulants. The INR of 3.0 is an expected finding. The aPTT should not be affected by warfarin and is also an expected finding.

A nurse is assessing a client who is sedated after sustaining a traumatic fall. Which physiologic response indicates the client may require pain medication? The client is diaphoretic. The client verbalizes an 8/10 pain. The client changes positions frequently. The client is grimacing.

The client is diaphoretic. Rationale: Acute pain stimulates the sympathetic nervous system. Diaphoresis is a sympathetic, physiologic response to pain. A numerical pain scale would not be indicated for a client who is sedated. The client would not be able to change positions frequently under sedation. Grimacing is a behavioral, not a physiologic, response to pain.

The nurse is monitoring a client who is taking prescribed nitroglycerin for angina. Which finding indicates the medication has a therapeutic effect? The client's blood pressure is 150/80 mm/Hg. The client's heart rate is 110. The client reports a decrease in chest pressure. The client reports a headache.

The client reports a decrease in chest pressure. Rationale: Nitroglycerin acts to decrease myocardial oxygen consumption. Dilatation of the veins reduces the amount of blood returning to the heart (preload), so the chambers have a smaller volume to pump resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by dilating coronary blood flow. While blood pressure may decrease slightly due to the vasodilatory effects of nitroglycerin, it is a secondary effect and not the desired therapeutic effect of this drug. Increased blood pressure and increased preload would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerin.

The nurse is caring for a client with a sore throat who developed urticaria after the administration of prescribed antibiotics. The client is now receiving cetirizine. Which finding indicates that the cetirizine is having the intended effect? The client reports less itching. The tonsils are decreasing in size. The client reports less muffled hearing. The pain rating is decreased.

The client reports less itching. Rationale: Cetirizine is a second-generation H1 receptor antagonist (antihistamine). Cetirizine binds preferentially to peripheral rather than central H1 receptors. This selectivity reduces the occurrence of drowsiness and CNS depression. Second-generation antihistamines are now commonly used to treat pruritis in urticaria. Almost any drug can lead to an allergic response, especially in the case of sore throats, which can be mononucleosis misdiagnosed as strep throat. A characteristic of infectious mononucleosis is that up to 90 percent of the time that amoxicillin or ampicillin is taken, a rash then develops. The pattern of the rash is commonly maculopapular in appearance. It is very itchy.

The nurse administered furosemide to a client with acute pulmonary edema. Which observation by the nurse would indicate that the client is experiencing an adverse side effect of the medication? A The client exhibits exertional dyspnea with walking. B The client's weight decreased by 2 lbs. in two days. C The client's blood pressure is 104/60 mmHg. D The client reports muscle cramps in both legs.

The client reports muscle cramps in both legs. Rationale: Pulmonary edema is a condition that can occur secondary to left-sided heart failure or volume overload. Pulmonary edema can happen very quickly as fluid accumulates in the lung fields (i.e., interstitial area and alveoli) due to an increase in hydrostatic pressure. Manifestations of acute pulmonary edema include dyspnea, tachypnea, cough, tachycardia, jugular venous distention, and hypertension. The hallmark treatment for pulmonary edema is diuretic therapy with a loop diuretic (i.e., furosemide). Furosemide, a potassium-wasting diuretic, can significantly decrease intravascular volume, thus leading to hypotension, dehydration, and/or hypokalemia. A blood pressure of 104/60 mmHg is considered a normal value. Weight loss of 2 lbs. in two days is considered normal for a client receiving a diuretic for pulmonary edema. Dyspnea with exertion is not a medication side effect and is to be expected until the pulmonary edema has resolved. Muscle cramps and spasms while receiving diuretic therapy could indicate hypokalemia, an adverse drug effect of furosemide.

The nurse is observing a new graduate nurse preparing to administer bumetanide 4 mg orally to a client with heart failure. Which client finding requires the nurse to intervene immediately? A The client has crackles in both lung bases. B The client has 4+ pitting edema in both lower legs. C The client's most recent blood pressure is 96/60 mmHg. D The client's most recent serum potassium level is 2.9 mg/dL.

The client's most recent serum potassium level is 2.9 mg/dL. Rationale: Bumetanide is a powerful, potassium-wasting loop diuretic. It promotes diuresis in clients suffering from heart failure (HF) and fluid retention. Prior to administration, the nurse should verify that the client's potassium level is within normal range (3.5 to 5.0 mg/dL). A serum potassium level of 2.9 mg/dL is very low. The new graduate nurse should hold the bumetanide and notify the health care provider (HCP) immediately. Bibasilar crackles and pitting edema are expected findings for a client with HF and are indications for the use of diuretics. Although loop diuretics can cause hypotension related to diuresis, a BP of 96/60 is within acceptable limits for a client with HF.

After abdominal surgery, a client with protein calorie malnutrition is receiving total parenteral nutrition (TPN). Which is the best indicator that the client's nutritional needs are being met? The client's surgical incision is healing normally. The client's fluid intake and output are balanced. The client's blood glucose is less than 110 mg/dL. The client's serum albumin level is 3.5 mg/dL

The client's surgical incision is healing normally. Rationale: Because poor incision/wound healing is a possible complication of malnutrition for this client, normal healing of the surgical incision is the best indicator of the effectiveness of the TPN in providing adequate nutrition for this client. Blood glucose levels are monitored during TPN administration to prevent hypo- and hyperglycemia but they do not indicate that the client's nutrition is adequate. Intake and output should also be monitored but they do not indicate if the TPN is effective. The albumin level is in the low-normal range, but it is not as good as an indicator of nutritional status as a total serum protein level or the normal wound healing.

A nurse is evaluating a client 10 minutes after the administration of 1 unit of packed red blood cells. Which clinical finding will the nurse immediately document in the client's medical record? The post-transfusion hemoglobin level The client's weight The pain level pre-transfusion The client's vital signs

The client's vital signs Rationale: Vital signs should be taken pre- and post-procedure to evaluate the client's response to blood products. Any significant changes from baseline should be reported to the healthcare provider. Ten minutes is not enough time to assess a post-transfusion hemoglobin level. The client's weight should not be affected by 1 unit of packed red blood cells. The client's response, including pain, should be assessed before, during, and after the transfusion.

The nurse is reviewing medication orders for a client who has requested something for pain. In the process, the nurse finds a newly written order for pain medication. The health care provider wrote, "Give APAP every six hours as needed for pain." Which part(s) of the medication order should the nurse clarify before administering the medication? Select all that apply. The indication The mechanism of action The dosage The frequency The route The drug name

The dosage The route The drug name Rationale: Medication orders must include the client, medication, route, dose, time, frequency, and indication. Medication abbreviations increase the risk of errors and should be eliminated from written orders. Not every nurse will know that APAP is an abbreviation for acetaminophen, therefore, the order should spell out the full, generic drug name. The nurse functions as the client's advocate and should collaborate with health care providers (HCPs) and pharmacists when they identify potential medication concerns. When reviewing a new medication order, the nurse must clarify each concern with the HCP prior to administration. It is not required to include how the drug works and other pharmacokinetic information in the prescription.

A nurse has administered acetaminophen for pain relief to an infant. Based on the client's development stage, which action is most important to include in the medication administration record? The dose administered based on the client's weight The client's pain level after administration of the medication The time the dose was administered to the client The client's vital signs before the medication was administered

The dose administered based on the client's weight Rationale: The most important action to document in the client's medical record is the dose administered. The dose of acetaminophen administered to infants is based on weight. Infants should not exceed more than 5 doses of 10-15 mg/kg/dose in a 24-hour period. Documenting the pain level after administration of analgesics, the time the dose was administered, and the latest vital signs should be performed on every client regardless of their developmental stage.

The nurse is interviewing a client about home medications. Which of the following information should the nurse document in the medical record as a part of the medication reconciliation? The client's demographic information The frequency of each medication The client's preferred pharmacy The name of the provider that prescribed each medication

The frequency of each medication Rationale: The medication reconciliation should be completed during the initial interview and should include the name of the medication(s), the dose, the frequency, and compliance to the prescribed medication regimen. The demographic information, the pharmacy information, and the prescribing provider are not included as a part of the medication reconciliation.

The nurse is reinforcing teaching about levothyroxine for a client newly-diagnosed with hypothyroidism. Which information should the nurse make sure to reinforce about this medication? A The medication will decrease the client's heart rate. B The medication must be stored in a dark container. C The medication may decrease the client's energy level. D The medication should be taken in the morning.

The medication should be taken in the morning. Rationale: A thyroid supplement, such as levothyroxine, should be taken on an empty stomach in the morning. Morning dosing minimizes the side effect of insomnia and an empty stomach facilitates absorption. The medication does not need to be stored in a dark container. Levothyroxine will cause an increase in the client's energy level and heart rate.

A charge nurse is observing a staff nurse prepare 1 ml of intravenous digoxin for a client with heart failure. After the staff nurse prepares the medication, the nurse notices precipitate in the syringe. Which action by the staff nurse likely caused this reaction? D5W was used as the diluent. The medication was not allowed to reach room temperature. The medication was added to 1 mL of diluent. Air was not inserted into the vial.

The medication was added to 1 mL of diluent. Rationale: When administering digoxin, 1 milliliter of digoxin should be mixed into at least 4 milliliters of diluent. Using a smaller amount of diluent will cause precipitation of the medication. Dextrose 5% in water (D5W) is compatible with digoxin and can be used to dilute the medication. Digoxin is not a temperature-controlled medication. Precipitation occurs as a result of incompatibilities or improper mixing. The insertion of air into a vial facilitates the withdrawal of the medication. Omission of this does not cause medication precipitation.

The nurse is caring for a client who is receiving regular insulin supplied in a glass vial. Which step(s) should the nurse take to ensure the correct administration of the insulin? Select all that apply. The nurse should rub the injection site after administering the insulin. The nurse should shake the insulin vial before drawing up the insulin. The nurse should only use an insulin syringe to administer insulin. The nurse should check the strength of the insulin before administering it. The nurse should store opened vials of insulin at room temperature The nurse should store unopened vials of insulin in the freezer. The nurse should discard the vial 28 days after it was opened.

The nurse should only use an insulin syringe to administer insulin. The nurse should check the strength of the insulin before administering it. The nurse should store opened vials of insulin at room temperature The nurse should discard the vial 28 days after it was opened. Rationale: Insulin is a medication that can be used to control blood glucose levels in clients with both type 1 and type 2 diabetes. Although there are many types of insulin, the act of administering insulin is similar regardless of the type. Unopened vials of insulin should be stored in the refrigerator, not the freezer. The nurse should gently roll the insulin vial back and forth prior to drawing up the medication. Shaking the vial could lead to the formation of bubbles in the syringe. To prevent a medication error, the nurse should only use an insulin syringe to administer insulin. Another way the nurse can prevent a medication error is to check the strength and dose of the insulin before administration. The nurse should not rub the injection site after administering the insulin, as it could alter the absorption of the medication. If necessary, lightly wipe the site with a piece of gauze after the injection. The vial in current use can typically be stored at room temperature for up to one month but must be kept out of direct sunlight and extreme heat.

The client is taking bupropion to treat depression and is worried about taking the medication. The client tells the nurse a friend said the medication was removed from the market because it caused seizures. What is an appropriate response by the nurse? A Omit the next dose until you talk with your health care provider. B Ask your friend about the source of this information. C Your health care provider knows the best drug for your condition. D The recommended dose of this medication was changed, which lowered the risk of seizures.

The recommended dose of this medication was changed, which lowered the risk of seizures. Rationale: Bupropion was introduced in the United States in 1985 and then withdrawn because of the occurrence of seizures in some clients who took the drug. The drug was reintroduced in 1989 with specific recommendations about dose ranges to limit the occurrence of seizures. The risk of seizure appears to be strongly associated with higher dosages.

A nurse is assessing a client's peripheral intravenous (IV) access prior to initiating a blood transfusion. Which finding will prompt the nurse to initiate new venous access? The IV site is on the client's wrist. The catheter has been in place for 72 hours. The skin around the IV site is cool to the touch. The IV catheter is a 20-gauge.

The skin around the IV site is cool to the touch. Rationale: Coolness surrounding the IV site is a sign of infiltration. The nurse should discontinue the IV access and initiate a new IV for the blood transfusion. An IV site on the wrist is not contraindicated. The nurse should ensure the IV is patent. IV catheters may be left in place according to manufacturer recommendations. The indwelling time of the catheter is not sufficient information to determine its patency. A 20-gauge catheter is acceptable for a blood transfusion. A large-bore catheter (18-20) should be used.

The nurse is teaching a client diagnosed with depression about a new prescription of nortriptyline. What information would be essential for the nurse to emphasize about this medication? Symptom relief occurs in a few days The medication must be stored in the refrigerator The use of alcohol should be avoided Episodes of diarrhea can be expected

The use of alcohol should be avoided Rationale: Nortriptyline is a tricyclic antidepressant used to manage chronic neurogenic pain and depression. Adverse reactions include central nervous system (CNS) side effects such as suicidal thoughts, drowsiness, fatigue, lethargy, and confusion. Clients who are prescribed this medication should be educated to avoid the use of alcohol consumption or other CNS depressant drugs as this can worsen the adverse reactions of the medication and cause injury.

The nurse is educating a client about newly prescribed alprazolam. Which information should the nurse include in the teaching? Tardive dyskinesia is common early in treatment. Administration of paroxetine may be needed to prevent adverse effects. The use of grapefruit juice should be avoided. Hyperactivity is seen with long-term use.

The use of grapefruit juice should be avoided. Rationale: Grapefruit or grapefruit juice is a known food-drug interaction and may increase drug levels of alprazolam to potentially toxic concentrations. Paroxetine when given with alprazolam will increase the incidence of adverse side effects. Alprazolam is used to treat tardive dyskinesia and is not an adverse side effect of this medication. In general, side effects of benzodiazepines with long-term use include drowsiness, lethargy, and weight gain but not hyperactivity.

The home care nurse is reviewing the medical record of a new client with a history of chronic obstructive pulmonary disease, atrial fibrillation and gout. After reviewing the client's medication list, for which medications should the nurse arrange to monitor blood levels? Select all that apply. Theophylline Allopurinol Beclomethasone Montelukast Digoxin

Theophylline Digoxin Rationale: It is necessary to monitor blood levels for theophylline and digoxin to prevent toxicity. Both of those drugs can accumulate in the blood and reach toxic levels. The other medications are not known to accumulate and cause toxicity if taken as prescribed.