MISSED ATI QUESTIONS
A nurse is caring for a client who is taking warfarin. The client reports that they have been taking 500 mg of acetaminophen three times per day to relieve osteoarthritis pain. Which of the following statements should the nurse make? "Acetaminophen is a good choice. Just be sure not to take any aspirin." "Acetaminophen can increase the effects of warfarin."
"Acetaminophen can increase the effects of warfarin." Acetaminophen interacts with warfarin to inhibit its metabolism and increase the effects, putting the client at risk for bleeding. The nurse should check the client's INR and monitor it carefully.
A nurse is teaching a client about cyclobenzaprine. Which of the following client statements should indicate to the nurse that the teaching is effective? "I will have increased saliva production." "I will continue taking the medication until the rash disappears." "I will taper off the medication before discontinuing it."
"I will taper off the medication before discontinuing it." The client should taper off cyclobenzaprine before discontinuing it to prevent abstinence syndrome or rebound insomnia.
A nurse is caring for a client who has acute acetaminophen toxicity. The nurse should anticipate administering which of the following medications? Vitamin K Acetylcysteine Benztropine
Acetylcysteine Acetylcysteine is a specific antidote for acetaminophen toxicity. It can prevent severe injury when given orally or by IV infusion within 8 to 10 hr.
A nurse is preparing to administer Rho(D) immune globulin to a female client who is 6 hr postpartum. Which of the following actions should the nurse take? Confirm the client is Rh-positive prior to administration. Administer the medication intramuscularly into the client's deltoid. Observe the client for an allergic reaction for 5 min following administration.
Administer the medication intramuscularly into the client's deltoid.
A nurse is preparing to administer medications to a client who is postoperative and has hypertension. To confirm that they are administering the medication to the correct client, which of the following actions should the nurse take? Ask the client to state their room number and bed number. Ask the client to state their name and telephone number.
Ask the client to state their name and telephone number. Appropriate client identifiers include the client's name, telephone number, facility identification number, and date of birth. The nurse must use at least two identifiers to make sure they are administering the medication to the correct client.
A nurse is providing teaching to a client who has multiple sclerosis and a new prescription for methylprednisolone. Which of the following instructions should the nurse include? (Select all that apply.) Blood glucose levels will be monitored during therapy. Avoid contact with people who have known infections. Take the medication 1 hr before breakfast. Decrease dietary intake of foods containing potassium. Grapefruit juice can increase the effects of the medication.
Blood glucose levels will be monitored during therapy is correct. The nurse should monitor the client for hyperglycemia while providing methylprednisolone to the client. Glucocorticoids, such as methylprednisolone, increase serum glucose levels and can require management with insulin or antihyperglycemics. Avoid contact with people who have known infections is correct. The nurse should instruct the client to avoid exposure to infectious agents, such as contact with those who have active infections or illnesses. Glucocorticoids, such as methylprednisolone, depress the immune system, placing the client at an increased risk for developing an infection. Grapefruit juice can increase the effects of the medication is correct. The nurse should instruct the client that grapefruit and grapefruit juice can increase the level of methylprednisolone in the body.
A nurse is reviewing the medication administration record of a client who has hypocalcemia and a new prescription for IV calcium gluconate. The nurse should identify that which of the following medications can interact with calcium gluconate? Felodipine Digoxin Regular insulin
Digoxin The nurse should identify that calcium gluconate can cause hypercalcemia, which increases the risk of digoxin toxicity.
A nurse is caring for a client who is taking atorvastatin for hyperlipidemia. Which of the following client laboratory values should the nurse monitor? Creatinine kinase Erythrocyte sedimentation rate International normalized ratio
Creatinine kinase The client who is taking atorvastatin can develop an adverse effect called rhabdomyolysis, which causes muscle weakness or pain and can progress to myositis. Creatinine kinase levels rise in response to enzymes released with muscle injury.
A nurse is caring for a client who has hypocalcemia and is receiving calcium citrate. The nurse should identify that which of the following findings indicates a therapeutic response to the medication? Positive Chvostek's sign Client report of decreased paresthesia Calcium level of 8.8 mg/dL
Client report of decreased paresthesia Paresthesia is a manifestation of hypocalcemia. A client report of a decrease in paresthesia is an indication of a therapeutic response to calcium citrate. The nurse should also monitor for a decrease in other manifestations of hypocalcemia, including muscle twitching and cardiac dysrhythmias.
A nurse is administering baclofen for a client who has a spinal cord injury. Which of the following findings should the nurse document as a therapeutic outcome? Increase in seizure threshold Decrease in flexor and extensor spasticity
Decrease in flexor and extensor spasticity A client who has a spinal cord injury and takes baclofen can experience a decrease in the frequency and severity of muscle spasms and in flexor and extensor spasticity.
A nurse is preparing to administer medications to a client who reports nausea, vomiting, and yellow vision. Which of the following of the client's medications should the nurse withhold? Digoxin Clindamycin
Digoxin The nurse should identify that the client has manifestations of digoxin toxicity, which is a contraindication for further administration of this medication. Other manifestations of digoxin toxicity include bradycardia, abdominal pain, and seeing halos around dark objects.
A nurse is administering cefotetan via intermittent IV bolus to a client who suddenly develops dyspnea and widespread hives. Which of the folowing actions should the nurse take first? Administer epinephrine Discontinue the medication IV infusionl
Discontinue the medication IV infusion. The greatest risk to the client is respiratory arrest from anaphylaxis. Therefore, the first action the nurse should take is to discontinue the medication IV infusion to prevent the client from receiving more medication. However, the nurse should not remove the IV catheter. Instead, the nurse should change the tubing and administer 0.9% sodium chloride by continuous IV infusion.
A nurse is assessing a client who just received filgrastim for myelosuppression. Which of the following findings should the nurse identify as an indication that the client is having an allergic reaction to this medication? Dyspnea Blurred vision
Dyspnea Filgrastim, a colony-stimulating factor, can cause allergic reactions. Manifestations include wheezing, hives, hypotension, angioedema, dyspnea, and tachycardia.
A nurse in an emergency department is caring for a client whose family reports the client has taken large amounts of diazepam. Which of the following medications should the nurse anticipate administering? Magnesium sulfate Flumazenil Protamine sulfate
Flumazenil The nurse should anticipate administering flumazenil, an antidote used to reverse benzodiazepines such as diazepam.
A nurse administered digoxin immune Fab to a client who received the incorrect dose of digoxin over a period of 3 days. The nurse should identify that which of the following findings indicates the antidote was effective? Normal sinus rhythm Digoxin level of 2.5 ng/mL
Normal sinus rhythm Dysrhythmias are a life-threatening adverse effect of digoxin toxicity. The return of the heart to normal sinus rhythm indicates a therapeutic response to the antidote. Digoxin immune Fab is administered to a client who is experiencing severe digoxin toxicity. It binds with digoxin and works to reduce the client's blood digoxin level.
A nurse is reviewing the laboratory results of a client who is taking digoxin for heart failure. Which of the following results should the nurse report to the provider? Calcium level 9.2 mg/dL Magnesium level 1.6 mEq/L Digoxin level 1.1 ng/mL Potassium level 2.8 mEq/L
Potassium level 2.8 mEq/L A potassium level of 2.8 mEq/L is below the expected reference range of 3.5 to 5 mEq/L. The nurse should notify the provider if a client has hypokalemia prior to administration of digoxin due to the increased risk of developing digoxin toxicity and cardiac dysrhythmias.
A nurse is reviewing the ECG of a client who is receiving IV furosemide for heart failure. The nurse should identify which of the following findings as an indication of hypokalemia? Presence of U-waves Widened QRS complex ST elevation
Presence of U-waves The nurse should identify the presence of U-waves as a manifestation of hypokalemia, an adverse effect of furosemide.
A nurse is developing a teaching plan for a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include in the teaching plan? (Select all that apply.) Report muscle pain to the provider. Avoid taking the medication with grapefruit juice. Take the medication in the early morning. Expect a flushing of the skin as a reaction to the medication. Expect therapy with this medication to be lifelong.
Report muscle pain to the provider is correct. Myopathy is an adverse effect of simvastatin that can lead to rhabdomyolysis. The nurse should instruct the client to report this to the provider. Avoid taking the medication with grapefruit juice is correct. When taken with grapefruit juice, simvastatin increases the risk of muscle injury from elevations in creatine kinase. Expect therapy with this medication to be lifelong is correct. If medication therapy is discontinued, cholesterol levels will return to their pretreatment range within several weeks to months.
A nurse is teaching a client who has a new prescription for montelukast about using the medication to prevent exercise-induced bronchospasm. Which of the following instructions should the nurse include? Take the medication once per day in the morning. Take the medication 15 min before exercising. Take the medication 2 hr before exercising.
Take the medication 2 hr before exercising. To prevent exercise-induced bronchospasm, the client should take a 10-mg tablet of montelukast at least 2 hr before they begin exercising.
A nurse is caring for a client who is taking acetazolamide for chronic open-angle glaucoma. For which of the following adverse effects should the nurse instruct the client to monitor and report? Tingling of fingers Oliguria
Tingling of fingers The nurse should instruct the client to report the adverse effect of paresthesia, a tingling sensation in the extremities, when taking acetazolamide.
A nurse is providing teaching to a client who is to start therapy with digoxin. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider? Dry coughx Pedal edema Yellow-tinged vision
Yellow-tinged vision The nurse should instruct the client to monitor for and report yellow-tinged vision, which is a sign of digoxin toxicity. Other manifestations of digoxin toxicity include nausea, vomiting, loss of appetite, and fatigue. As the digoxin levels increase, the client can experience cardiac dysrhythmias.
