Passpoint IV and drug admin
When positioned properly, the tip of a central venous catheter should lie in the
superior vena cava. Explanation: When positioned correctly, the tip of a central venous catheter lies in the superior vena cava, inferior vena cava, or right atrium — that is, in the central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilic, jugular, and subclavian veins are common insertion sites for central venous catheters.
The parent of a 28-year-old client who is taking clozapine states, "Something's wrong. My son is drooling like a baby." What response by the nurse would be most helpful?
"Excess saliva is common with this drug; here's a paper cup for the client to spit into." Explanation: Telling the parent that excess saliva is a common adverse effect of the drug is most helpful because it gives the parent information about the problem, thereby helping to decrease anxiety about what is occurring with the client. By offering the paper cup, the nurse also demonstrates concern for the client, thereby leading to increased trust. Saying "I wonder if they are having an adverse reaction to the medicine" shows the nurse's lack of knowledge about the drug, decreases confidence in the nurse, and indicates poor judgment. Saying "Don't worry about it, it's only a minor inconvenience compared to its benefits" or telling the parent that the nurse has seen this happening to other clients is insensitive and does not assuage the parent's anxiety.
The nurse performs medication teaching for a client prescribed disulfiram. Which client statement indicates to the nurse that the client needs further teaching about disulfiram?
"I can drink one or two beers and not get sick while on disulfiram." Explanation: Any amount of alcohol consumed while taking disulfiram can cause an alcohol-disulfiram reaction. The reaction experienced is in proportion to the amount of alcohol ingested. The alcohol-disulfiram reaction can begin 5 to 10 minutes after alcohol is ingested. Symptoms can be mild, as in flushing, throbbing in the head and neck, nausea, and diaphoresis. Other symptoms include vomiting, respiratory difficulty, hypotension, vertigo, syncope, and confusion. Severe reactions involve respiratory depression, convulsions, coma, and even death. Disulfiram can be taken at bedtime if the client feels sleepy from the medication. Some clients experience a metallic or garlic taste when initiating disulfiram treatment. Anything containing alcohol, such as cough medicine, aftershave lotion, and mouthwash, can cause a reaction. Therefore, the client needs to check the labels of these items for their alcohol content.
The nurse instructs the client in mixing and administering regular and NPH insulin. Which statement indicates that the client needs additional instruction?
"I shake the bottle of NPH insulin before drawing it up." Explanation: When instructing the client about mixing two types of insulin in the same syringe, the nurse should instruct the client about how to handle the insulin and which one to draw up first. NPH insulin should be rolled between the palms to mix it before drawing it up; shaking it will introduce air bubbles into the solution, which can cause inaccurate dosing. The nurse should also verify that the client understands they should draw up the most rapid-acting insulin first; the client states they are drawing up the regular insulin first. Additionally, the nurse can verify that the client understands to store the insulin in a cool place and inject the insulin at a 90-degree angle.
The nurse is preparing a teaching plan for a client about general anesthesia induction. Which explanation would be most appropriate?
"You will breathe in an inhalant anesthetic mixed with oxygen through a facial mask and receive intravenous medication to make you sleepy." Explanation: Adult clients are induced for general anesthesia by breathing in an inhalant anesthetic mixed with oxygen through a facial mask and receiving IV medication to make them sleepy. Clients are not induced with the premedication. Clients usually are not induced with the IV infusion or the mask alone.
The nurse is preparing to administer a chemotherapy infusion to a client with esophageal cancer. The client has an implanted port that was last accessed 7 days ago. The insertion site is clean and dry and without erythema. Which is the appropriate action by the nurse?
Access the port using a Huber needle. Explanation: Implanted ports are designed for intermittent access; for the port to be last accessed 7 days ago is within accepted standards. There are no signs or symptoms of an infection at the site. Therefore, the nurse does not need to contact the healthcare provider or complete an incident report. The nurse should access the port with a Huber needle, which is designed for use in implanted ports. A coring needle will damage the implanted port. As the port is without signs and symptoms of complications, it should be utilized for the chemotherapy versus a peripheral line.
Just prior to administering lorazepam 2 mg I.V. to an agitated client, the client knocks the medication to the floor. After retrieving the medication, what is the best action by the nurse?
Ask another nurse to witness the waste of the medication. Explanation: Lorazepam is a Schedule IV controlled substance. Federal law requires two nurses to witness and document the waste of all controlled substances in order to prevent diversion and misuse of the substance. The nurse should ask another nurse to witness the waste of the medication either into the sink or an approved pharmaceutical waste container as per the facility policy. Controlled substances should never be placed into a sharps container as these are not secure and may lead to diversion of the substance. A nurse would not administer a medication that had been knocked to the floor as this would result in contamination of the syringe.
A client with chronic obstructive pulmonary disease has a new prescription for theophylline. Which information obtained from the client would prompt the nurse to consult with the healthcare provider? The client takes cimetidine 150 mg daily.
Cimetidine interferes with the metabolism of theophylline and may cause theophylline toxicity. Theophylline should be taken as prescribed even if the client is not experiencing any symptoms of shortness of breath. An elevated heart rate is an expected side effect of theophylline and moderate exercise in a client with COPD. Thick mucus production is also an expected symptom of COPD.
The physician's order reads "digoxin 0.075 mg." The pharmacy packaging contains three digoxin tablets labeled as 0.25 mg each. The packaging states to administer all 3 tablets to the client. What should the nurse do next?
Contact the pharmacist because the delivered dose is too high. Explanation: Three pills of 0.25 mg equal 0.75 mg, more than the 0.075 mg that was ordered. Because the quantity of medication differs from that ordered, the nurse should not administer it. The next step is to contact the pharmacist, who can check the order, verify its appropriateness, and deliver the dose that matches the order.
A client who is taking lithium carbonate is going home on a 3-day pass. What is the best health teaching the nurse should provide for this client?
Continue to maintain normal sodium intake while at home. Explanation: Lithium decreases sodium reabsorption by the renal tubules. If sodium intake is decreased, sodium depletion can occur. In addition, lithium retention is increased when sodium intake is decreased. Reduced sodium intake can lead to lithium toxicity. Nursing is not allowed to tell a client to adjust dosages of any drugs. A low-protein snack is not reflective or needed with this drug. Avoiding participation is not a therapeutic discussion
A client has a nasogastric (NG) tube. How should the nurse administer oral medication to this client?
Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube. Explanation: To administer oral medication through an NG tube, the nurse must reproduce the disintegration and dissolution processes by crushing the tablets and preparing a liquid form. Making sure not to crush sustained-release tablets or empty capsules, the nurse then inserts the liquid into the NG tube. Heating the tablets may destroy or alter the drug's action. Washing cut tablets or crushed powder down the tube may cause the medication to stick to the sides of the tube, possibly providing inaccurate dosing and clogging the tube.
The client's blood sugar is 210 mg/dL (11.7 mmol/L) this morning. The nurse verifies a dose of 8 units of regular insulin from the sliding scale. Which sites are acceptable for the nurse to administer the insulin? Select all that apply.
For a subcutaneous injection of insulin, the nurse should pick from these areas with adipose tissue beneath the skin: upper outer thighs, upper outer arms, abdomen, or buttocks. The deltoids are an intramuscular area, and the inside forearm lacks a fatty pad beneath the skin
The nurse is instructing a sexually active female who is taking isoniazid (INH). What should the nurse tell the client? INH:
INH interferes with the effectiveness of hormonal contraceptives, and female clients of birth age should be counseled to use an alternative form of birth control while taking the drug. INH does not increase the risk for vaginal infection, nor does it affect the ova or ovulation.
A client is receiving warfarin for newly diagnosed atrial fibrillation. Which laboratory result would indicate that the nurse should withhold the medication and contact the health care provider?
INR is the diagnostic test used to determine the effectiveness of warfarin. The therapeutic range for clients with atrial fibrillation is 2 to 3. The nurse should contact the health care provider because the client's INR exceeds the normal range. APTT is the diagnostic test for clients receiving heparin.
Which technique is correct when administering a subcutaneous injection?
Insert the needle at a 45-degree angle to the skin. Explanation: Subcutaneous injections are administered at an angle of 45 to 90 degrees, depending on the size of the client. Subcutaneous needles are typically to 1/2 to 5/8 inches (1.3 to 1.6 cm) in length. The skin should be pinched up at the injection site to elevate the subcutaneous tissue. Air is not drawn into the syringe for a subcutaneous injection.
A client is asking about dietary modifications to counteract the long-term effects of prednisone. What is the most appropriate information for the nurse to give the client? "Increase your intake of calcium and vitamin D."
Problems associated with long-term corticosteroid therapy include sodium retention, osteoporosis, and hyperglycemia. An increase in calcium and vitamin D is needed to help prevent bone deterioration. Dietary modifications need to reduce sodium, maintain high protein levels for tissue repair, and reduce carbohydrates, as there is a tendency toward hyperglycemia. Increased intake of complex carbohydrates is not indicated because of hyperglycemia. There should be decreased fat intake because there is a tendency for central fat deposition.
While attempting to obtain a blood sample from a peripherally inserted central catheter (PICC) line with a nonocclusive dressing, the nurse inadvertently dislodges the catheter. The catheter did not come all the way out and is still partially inserted. What should the nurse do first?
Secure the catheter and call the health care provider. Explanation: If a PICC line is dislodged and does not come all the way out, the health care provider needs to be notified after the line is secured. The health care provider may order a chest x-ray to determine where the tip is located. Changing the dressing and documenting the incident do not address the concern. The nurse should not push the catheter back into place.
A medication order reads, "Meperidine 1 ml I.M. stat." A nurse responsible for administering the drug should base the next action on which understanding?
The nurse should clarify the order with the physician. Explanation: The nurse must clarify this order with the physician because meperidine is available in several dosage strengths, and 1 ml may contain varying amounts of the drug. A stat order need not specify a precise administration time. Meperidine is commonly given I.M. Because the order specifies the drug volume but not the dosage, the nurse shouldn't consider this order correct and valid.
The nurse should establish baseline data on a client who is starting on long-term gentamicin sulfate therapy. Which is least important for assessment screening in this client?
Visual acuity. Explanation: Visual acuity is not affected by long-term gentamicin sulfate therapy. The nurse should establish baseline data for vestibular, renal, and auditory function because gentamicin sulfate is ototoxic and causes renal toxicity.
The clinic nurse is working with a client with dysuria who is prescribed phenazopyridine. What information should the nurse include in the client's teaching concerning this medication?
You should expect to see red-orange urine when taking phenazopyridine." Explanation: The nurse should explain that phenazopyridine can turn urine red-orange and may stain clothing or contact lenses. Phenazopyridine does not cause respiratory depression, candidiasis, or hypotension.
A nurse is administering sublingual nitroglycerin to a client. Immediately after administering nitroglycerin, the nurse should expect to administer
acetaminophen. Explanation: In the early stages of therapy, nitroglycerin commonly causes headache and dizziness. Acetaminophen usually helps decrease nitroglycerin-induced headaches. Although the client may be anxious, lorazepam usually isn't given after nitroglycerin. There is no indication that the client would need insulin or prednisone.
A multiparous client tells the nurse that she is using medroxyprogesterone injections for contraception. The nurse should instruct the client to increase her intake of which nutrient?
calcium Explanation: The nurse should instruct the client to increase her intake of calcium because there is a slight increase in the risk of osteoporosis with this medication. Weight-bearing exercises are also advised. The drug may also impair glucose tolerance in women who are at risk for diabetes.
The nurse is teaching the client with a hiatal hernia about taking metoclopramide hydrochloride. Which medication should the client avoid while taking this drug?
central nervous system depressants Explanation: Metoclopramide hydrochloride can cause sedation. Alcohol and other central nervous system depressants add to this sedation. A client who is taking this drug should be cautioned to avoid driving or performing other hazardous activities for a few hours after taking the drug. Clients may take antacids, antihypertensives, and anticoagulants while on metoclopramide.
When a nurse tries to administer medication, the client refuses it, saying, "I don't have to take those pills if I don't want to." What intervention by the nurse would have the highest priority?
exploring how the client's feelings affect the decision to refuse medication Explanation: By helping the client explore their feelings about the change in health status, the nurse can determine how these feelings affect the decision to refuse medication. Then the nurse can help the client develop new ways to satisfy self-care, esteem, and other needs and, ultimately, participate fully in the therapeutic regimen. Insisting that the client take the medication, reporting the client's comments to the physician, and explaining the consequences of not taking the medication are inappropriate because these actions do not explore the client's feelings
The nurse is monitoring a client who was given midazolam during a moderate sedation procedure. In the immediate postprocedure phase, the client becomes unresponsive to painful stimuli and apneic. The nurse should give which medication?
flumazenil Explanation: Flumazenil is a benzodiazepine antagonist and is used to reverse benzodiazepines such as midazolam, and the nurse should give flumazenil to this client who is showing symptoms of a benzodiazepine overdose. Propofol is a sedation medication, and would not be indicated for central nervous system depression and apnea. Ketorolac is a nonsteroidal anti-inflammatory pain medication and would not be helpful for this client. Naloxone is an opioid antagonist, and reverses the effects of narcotic pain medications, but does not reverse midazolam because it is a benzodiazepine, not an opioid.
What should a nurse expect to find while assessing the vital signs of a client who has abruptly stopped taking beta-adrenergic blocker?
irregular pulse Explanation: Abrupt withdrawal of a beta-adrenergic blocker results in rebound cardiac excitation, which causes ventricular arrhythmias and an irregular pulse. Abnormally low blood pressure would be unlikely because beta-adrenergic blockers are used to treat hypertension. Abrupt withdrawal of this medication wouldn't directly affect a client's respiratory rate.
The client is started on simvastatin to lower cholesterol. The nurse should explain to the client that which laboratory test will be monitored to detect potential side effects while the client is taking this drug?
liver function tests Explanation: Liver function tests, including aspartate transaminase (AST), should be monitored before therapy, 6 to 12 weeks after initiation of therapy or after dose elevation, and then every 6 months. If AST levels increase to three times normal, therapy should be discontinued. Simvastatin does not influence serum glucose, complete blood count, or total protein. Serum cholesterol and triglyceride levels should be evaluated before initiating therapy, after 4 to 6 weeks of therapy, and periodically thereafter.
The nurse should instruct a client who is taking dexamethasone and furosemide to report which symptom?
muscle weakness Explanation: The nurse should instruct the client who is taking dexamethasone and furosemide to observe for signs and symptoms of hypokalemia, such as malaise, muscle weakness, vomiting, and a paralytic ileus, because both dexamethasone and furosemide deplete serum potassium. This combination of drugs does not cause the client to become excitable or have diarrhea or thirst.
A client is to receive intravascular chemotherapy for 10 days. Which equipment should the nurse use for this procedure?
peripherally inserted central catheter (PICC) Explanation: When the duration of intravascular therapy is likely to be more than 6 days, a midline catheter or a PICC is preferred to a short peripheral catheter. In adult clients, use of the femoral vein for central venous access should be avoided. Steel needles should be avoided when administering fluids and medications that might cause tissue necrosis if extravasation occurs
An older adult is receiving morphine to manage pain after abdominal surgery. The nurse should observe the client for which side effect of this drug?
respiratory depression Explanation: It is especially important for the nurse to carefully assess the elderly client for respiratory depression after administering a dose of meperidine. It may be necessary to reduce the dosage to prevent respiratory depression. Dysrhythmias, constipation, and seizures are all potential adverse effects of meperidine, but respiratory depression is most significant in the elderly.
Which sign should the nurse closely assess in a client who is reversing from general anesthesia and receiving clindamycin?
respiratory depression Explanation: The client who has received general anesthesia with neuromuscular blocking agents must be carefully monitored when given clindamycin. A serious interaction could be enhanced, neuromuscular blockage, skeletal muscle weakness, or respiratory depression, if this combination is used during or immediately after surgery. Concurrent use should be avoided. The combined effect of the medications places the client at increased risk, and the nurse should assess the client closely for respiratory depression or paralysis. The nurse will be monitoring the client's heart rate, blood pressure, and urinary output but not specifically because of potential drug interactions and adverse effects of clindamycin.
The nurse is caring for a client who has a new prescription for amitriptyline for depression and is preparing to be discharged. What assessment is the nurse's priority?
suicidal ideation Explanation: All the listed side effects can occur with tricyclic antidepressants (TCAs). However, due to the high risk for fatal overdose when ingested for suicide attempt, the nurse's priority is to assess for suicidal ideation. Other precautions include limiting the supply of TCAs dispensed to decrease the risk for fatal overdose. If active suicidal ideation is present, the nurse should notify the prescribing healthcare provider prior to discharging the client. TCAs do cause anticholinergic effects, which include dry mouth, constipation, nausea, vomiting, and urinary retention. There is also a risk for extrapyramidal side effects and orthostatic hypotension, so the nurse should teach the client about these. None of these, however, are priority over assessing for suicide risk at the time of discharge.
When injecting an intravenous push medication into intravenous tubing with a solution infusing, the nurse should select which injection port?
the port closest to the client Explanation: The nurse should inject the medication into the port closest to the client. Administering the medication higher in the tubing makes flushing the tubing difficult and has the potential to interfere with the rate of administration, either of which could alter complete delivery of the medication.
A client is taking vancomycin. The nurse should report which possible side effect to the health care provider?
tinnitus Explanation: The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated with vancomycin.
The nurse is evaluating the effectiveness of fluid replacement for a client in hypovolemic shock. Which finding is the best indication that fluid replacement is adequate?
urine output greater than 30 mL per hour Explanation: Urine output provides the most sensitive indicator of the client's response to therapy for hypovolemic shock. Urine output should be consistently greater than 35 mL per hour. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in a client recovering from hypovolemic shock
The nurse is preparing to give an intramuscular (IM) injection to an underweight client. Which site is the safest?
vastus lateralis Explanation: The vastus lateralis site is the preferred IM site for all ages because it does not have any major nerves or blood vessels located near it. The deltoid and dorsogluteal muscles have major nerves and blood vessels located nearby. The triceps is not an acceptable muscle for IM injections because it is not well developed in most clients.
A client's caretaker calls the home care nurse and states accidentally puncturing the central venous catheter after discontinuing the total parenteral nutrition. What instructions should the nurse provide to the caretaker?
Clamp the catheter. Explanation: The nurse should instruct the caretaker to clamp the catheter to prevent the client from experiencing an air embolism. The client should be positioned on the left side with head lower than the feet, not higher. The catheter should not be removed by the caretaker; it will need to be removed in an acute care or outpatient setting by a healthcare provider. As the client is not experiencing signs or symptoms of an air embolism or other complication, there is no need to contact 911 at this time.
When admitting a neonate whose mother received magnesium sulfate, the nurse should assess the baby for which complication? Select all that apply.
Magnesium sulfate decreases muscle contractility and crosses the placenta. Because of this, a neonate that has been exposed to this drug may have decreased muscle tone and decreased respirations. The Moro reflex will be decreased because of the decreased muscle tone. There are no findings that show magnesium sulfate has a direct effect on temperature.
The nurse is administering a subcutaneous injection (view the figure). After the nurse releases the skin and before the nurse injects the medication, the needle pulls out of the skin. What should: the nurse do next?
Correct response: Discard the needle, attach a new needle to the syringe, and administer the medication. Explanation: If the needle becomes dislodged from the tissue before the nurse administers the medication, the nurse should discard the needle, attach a new needle, and reattempt to administer the medication using the appropriate technique. The nurse should not reuse the needle but can reuse the syringe and medication. To administer a subcutaneous injection, the nurse should bunch the skin around the insertion site (not stretch the skin) to lift the subcutaneous tissue from the muscle.
A client takes hydrochlorothiazide (HCTZ) for treatment of hypertension. The nurse should instruct the client to report which effect(s)? Select all that apply.
HCTZ is a thiazide diuretic used in the management of mild-to-moderate hypertension and in the treatment of edema associated with heart failure, renal dysfunction, cirrhosis, corticosteroid therapy, and estrogen therapy. It increases the excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule of the kidneys. It promotes the excretion of chloride, potassium, magnesium, and bicarbonate. Side effects include drowsiness, lethargy, and muscle weakness but not muscle twitching. Although there may be abdominal cramping, there is no diarrhea. The client does not become confused as a result of taking this drug.
What is the priority action that a nurse should take after omitting an ordered medication?
Notify the prescriber. Explanation: A nurse who has omitted an ordered medication should prioritize the notification of the prescriber. The nurse should then document the omission and the reason it occurred in the client's chart and, depending on facility policy, write an incident report. Depending on the facility's policy, the nursing supervisor may need to be notified but this would be done after the prescriber has been notified.
When teaching a client older than age 50 who is receiving long-term prednisone therapy, the nurse should make which suggestion?
Take the prednisone with food. Explanation: Nausea, vomiting, and peptic ulcers are gastrointestinal adverse effects of prednisone, so it is recommended that clients take the prednisone with food. In some instances, the client may be advised to take a prescribed antacid prophylactically. The client should never take over-the-counter drugs without notifying the health care provider (HCP) who prescribed the prednisone. The client should ask the HCP about the amount and kind of exercise because of the need to establish baseline physical values before starting an exercise program and because of the increased potential for comorbidity with increasing age. The client should eat foods that are high in potassium to prevent hypokalemia.
When developing a teaching plan for a client taking hormonal contraceptives, a nurse should ensure that the client knows she must have which vital sign monitored regularly? BP
The incidence of hypertension is three to six times greater in clients using hormonal contraceptives than in women who don't use these drugs. Age and duration of the drug's use increase this incidence. Hormonal contraceptives don't directly affect pulse, respirations, or temperature.
A client who is using a patient-controlled analgesia (PCA) pump after bowel surgery states, "I'm afraid that I'll become addicted if I use too much morphine." Which would be the best response by the nurse?
When morphine is used to alleviate severe pain for 2 to 3 days, there is little likelihood of becoming addicted." Explanation: Morphine is a narcotic. Clients need to understand that when pain is present and morphine is used therapeutically, there is less likelihood of addiction. If morphine is taken in the absence of pain, addiction can result. Telling the client that morphine is not addicting in this circumstance is incorrect because, although it acknowledges the addictive nature of morphine, it does not inform the client of its utility in pain management. Asking about prior drug addiction is not appropriate at this time; the client would be assessed for risk of addiction or abuse before extended-release or long-acting forms of morphine were prescribed, but these forms are generally not used for postoperative pain.
The nurse reviews a client's medication administration record and notes the scheduled medications (see chart). When planning to administer the medications, the nurse must administer which medication within 30 minutes of its scheduled administration time?
ampicillin Explanation: Time-critical medications are those medications that can cause client harm or subtherapeutic blood levels and should be administered within 30 minutes of the scheduled time. These include antibiotics, anticoagulants, immunosuppressants, insulin, and antiseizure medications. Non-time-critical medications, such as lisinopril, metoprolol, and the pneumococcal vaccine, should generally be administered within 1 to 2 hours of the scheduled time. However, agency policy dictates the window of time to administer non-time-critical medications and may vary by institution.
A client is receiving total parenteral nutrition (TPN) solution. The nurse should assess a client's ability to metabolize the TPN solution adequately by monitoring the client for which sign?
hyperglycemia Explanation: During TPN administration, the client should be monitored regularly for hyperglycemia. The client may require small amounts of insulin to improve glucose metabolism. The client should also be observed for signs and symptoms of hypoglycemia, which may occur if the body overproduces insulin in response to a high glucose intake or if too much insulin is administered to help improve glucose metabolism. Tachycardia or hypertension is not indicative of the client's ability to metabolize the solution. An elevated blood urea nitrogen concentration is indicative of renal status and fluid balance.
The health care provider (HCP) has prescribed nitroglycerin to a client with angina. The client also has closed-angle glaucoma. The nurse should contact the HCP to discuss the potential for which drug interaction?
increased intraocular pressure Explanation: Nitroglycerin causes vasodilation, which results in increased intraocular pressure. The vasodilatory effects of the medication can trigger an attack, causing pain and loss of vision. Hypotension is a common side effect of nitroglycerin, which dilates the blood vessels but is not a concern in the client with glaucoma.
During gentamicin therapy, the nurse should monitor a client's
serum creatinine level. Explanation: During gentamicin therapy, the nurse should monitor a client's serum creatinine level because the most notable adverse reactions to aminoglycoside therapy are nephrotoxicity and ototoxicity. The drug doesn't appear to affect serum potassium or glucose levels or PTT.
A client is taking acetylsalicylic acid (ASA) for pain control. Which finding should the nurse report to the healthcare provider immediately?
ringing in the ears Explanation: A symptom of ASA toxicity is tinnitus and must be reported to the healthcare provider. Constipation, muscle aches, and GI upset are not adverse effects or indicators of toxicity of ASA.
When administering an I.V. medication through a central line, the nurse notes that a client's central line gauze dressing was last changed 24 hours previously. What is the appropriate action by the nurse?
Proceed to administer the I.V. medication. Explanation: Gauze dressings should be changed every 2 days so the nurse should proceed to administer the medication. There is no need for an incident report or to contact the healthcare provider.
The health care team has noticed an increase in intravenous (IV) infiltrations on the pediatric floor. As part of a "Plan, Do, Study, Act" quality improvement plan, the team should perform the actions in which order? All options must be used.
Decide to monitor IV gauges. Perform chart audits. Analyze the data. Write a new IV insertion policy. Explanation: Deciding what to study and how to do it is part of the planning process. Collecting data through chart audits is part of the "do" phase. Once the chart audits are complete, the data may be "studied" or analyzed. The final step of the process, or the "act" phase, is to determine what should be done, which may include writing a new policy.
A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do?
Discontinue the current solution, change the tubing, and hang a new bag of TPN solution. Explanation: IV fluids should not be infused for longer than 24 hours because of the risk for bacterial growth in the solution. The appropriate action for the nurse to take is to discontinue the current TPN solution, change the tubing, and hang a new bag of solution. Changing the filter does not decrease the risk for contamination. Notifying the HCP for a change in flow rate is not an acceptable solution.
The nurse is reviewing the laboratory report with the client's lithium level before administering the 1700 hours dose. The lithium level is 1.8 mEq/L (1.8 mmol/L). What action should the nurse take?
Hold the 1700 hours dose of lithium. Explanation: The nurse should hold the 1700 hours dose of lithium because a level of 1.8 mEq/L (1.8 mmol/L) can cause adverse reactions, including diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination, which are early signs of lithium toxicity. The nurse should report the lithium level to the health care provider, including any symptoms of toxicity. Administering the 1700 hours dose of lithium, giving the client the lithium with 240 mL of water, or giving it after supper would increase the lithium level, thus increasing the risk for lithium toxicity. normal: .6-1.2
A nurse is preparing to administer digoxin elixir to a client. Which principle regarding this medication is correct?
Liquid digoxin should be measured with a calibrated dropper or syringe. Explanation: The adult therapeutic level for digoxin is 0.5 to 2 ng/ml (1.0 - 2.6 nmol/L). This narrow therapeutic range makes digoxin toxicity likely, so the nurse must measure liquid preparations with calibrated droppers or syringes. Digoxin toxicity commonly causes life-threatening cardiac arrhythmias. The nurse should hold and notify the physician about digoxin for heart rates below 60 beats/minute.
A 75-year-old client who has been taking furosemide regularly for 4 months tells the nurse about having trouble hearing. What should the nurse do?
Report the hearing loss to the health care provider. Explanation: Furosemide may cause ototoxicity. The nurse should tell the client to promptly report the hearing loss, dizziness, or tinnitus to help prevent permanent ear damage. Hearing loss is not inevitable, and it is inappropriate to make assumptions about the cause of symptoms without a thorough evaluation. The client's system will not "adjust," and hearing loss will not resolve.
A loading dose of digoxin is given to a client newly diagnosed with atrial fibrillation. The nurse instructs the client about side effects of the medication to monitor. Which response indicates the client has understood the instruction? The client can:
The most serious side effect of digoxin is slow heart rate; the nurse should instruct the client to take the pulse and observe that the client can accurately locate and count the radial pulse. While the nurse can ask the client to explain how to take the medication, why it is necessary to do so, and its actions, the most important outcome is to be sure the client can take the pulse and recognize an abnormally slow heart rate.
The client presents at the clinic for a cough and is ordered codeine. What should the nurse include in the client's teaching concerning the administration of codeine? Select all that apply.
The nurse should explain that adverse effects of codeine include dizziness, nausea, and constipation. Muscle impairment and GI bleeding are not among the adverse effects of codeine, so these should not be noted to the client..
The client was diagnosed with hypertension 7 years ago. In the last 6 months, after diet and exercise, the client's blood pressure has consistently ranged around 160/95. What should the nurse include in the client's teaching about the side effects of clonidine? Select all that apply.
The nurse should explain that side effects of clonidine include orthostatic hypotension, drowsiness, peripheral edema, fatigue, urinary retention, dry mouth, and constipation. Hematuria and arthralgia are not side effects of clonidine.
The health care provider orders ibuprofen for a client reporting pain. What should the nurse include in the client's teaching concerning ibuprofen? Select all that apply
The nurse should teach the client to notify their health care provider of dark tarry stools, coffee ground emesis, frank blood emesis, or other GI distress, as well as blood or protein in the urine and onset of skin rash, pruritus, and jaundice. The nurse should teach the client not to take aspirin concurrently with ibuprofen and not to drive or engage in potentially dangerous activities until drug response is known. Teaching should not include avoiding exposure to strong sunlight or avoiding over-the-counter medications.
The nurse is to inject an intravenous medication via a locked peripheral intravenous port. The nurse flushes the port with saline, administers the intravenous medication, and again flushes the port with saline. During this process, when should the nurse clean the injection port with an antiseptic swab?
at each entry of the capped injection port Explanation: The nurse should clean the capped injection port prior to each time it is entered. It is not necessary to clean the injection port at other times, and the other options do not address the importance of cleaning a port before every entry.
A client is receiving a blood transfusion, and 1 hour after starting the transfusion the client reports dyspnea and has crackles on lung auscultation. Which medication would be most important for the nurse to give?
furosemide 40 mg I.V. Explanation: This client is experiencing fluid overload usually noted after the first 15 minutes. The treatment of choice would be a diuretic. Acetaminophen would used to treat a febrile reaction; methylprednisolone and diphenhydramine would be indicated in an allergic reaction, which does not normally cause crackles.
A client with heart failure is given a prescription for torsemide. Two days after the drug therapy is started, which sign indicates the drug is having the intended outcome? The client:
weighs 7 lb (3 kg) less than the client did 2 days ago. Explanation: The primary reason to give a diuretic to a client with heart failure is to promote sodium and water excretion through the kidneys. As a result, the excessive body water that tends to accumulate in a client with heart failure is eliminated, which causes the client to lose weight. Monitoring the client's weight daily helps evaluate the effectiveness of diuretic therapy. Clients should be advised to weigh themselves daily. An increased appetite or decreased thirst does not establish the effectiveness of the diuretic therapy, nor does having clearer urine after starting torsemide.
A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?
Gently aspirate the I.V. catheter to check for a blood return. Explanation: Before administering an I.V. bolus, the nurse should gently aspirate the I.V. catheter for a small amount of blood to ensure correct placement of the I.V. catheter. Then the nurse may inject the medication over the recommended time interval. The nurse doesn't need to insert another I.V. line unless the ordered medication is incompatible with the medication in the I.V. solution. Warming the medication could alter the drug's action. Placing a tourniquet on the arm would close off the venous system and prevent drug injection.
The student nurse is planning to care for a peripheral intravenous (I.V.) site for a client receiving chemotherapy. Which outcome would demonstrate that the student understands the concepts of I.V. care?
If extravasation is suspected, stop the infusion. Explanation: Peripheral venous access devices are commonly used for clients receiving long-term chemotherapy, total parenteral nutrition, or frequent medication or fluids. These devices may remain in place for several weeks to more than 1 year if no complications develop. Extravasation, or infiltration of the drug into surrounding tissue, is an emergency, and the priority action is to stop the infusion. The site could be cleaned and dressing changed more often than every 72 hours depending on the type of dressing, patient's condition, and other factors. Heparin is not used to flush peripheral sites. Nurses monitor I.V. sites more frequently than every 24 hours; the site should be checked at least every 4 hours.
A nurse receives a report that a client has had an overdose of heparin. Which action by the nurse is most important in managing the overdose?
Obtain an order to give protamine sulfate. Explanation: Protamine sulfate is the reversal agent for heparin. Administering this would be the best way to treat the client. The other options do not reverse heparin and therefore will not treat the overdose.
