Module 8 - No Rationale

The emergency department staff prepares for the arrival of a child who has ingested a bottle of acetaminophen (Tylenol). Which medication does the nurse ensure is available?

Acetylcysteine (Mucomyst).

A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely?

Akathisia.

A nurse is providing instruction to a client who is taking codeine sulfate for severe back pain. The nurse should tell the client to:

Maintain a high-fiber diet.

A physician prescribes 1000 mL of 5% dextrose in water to be infused over 8 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round your answer to the nearest whole number).

31

A nurse is reviewing the laboratory results of a client receiving intravenous chemotherapy. Which of the following laboratory findings prompts the nurse to initiate neutropenic precautions?

A white blood cell (WBC) count of 2.0 x 103/uL (2.0 x 109/L)

A client has been given a prescription to begin using nitroglycerin transdermal patches for the management of angina pectoris. The nurse tells the client to:

Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed.

A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis?

Atropine sulfate.

A nurse has taught a client who is taking lithium carbonate (Lithobid) about the medication. The nurse determines that the client needs additional teaching if the client states that:

It is important to decrease fluid intake while taking the medication to avoid nausea.

A nurse is providing dietary instructions to a client taking spironolactone (Aldactone). Which of the following foods does the nurse instruct the client to avoid? Select all that apply.

Bananas, Citrus fruits.

A nurse discontinues infusion of a unit of blood after the client experiences a transfusion reaction. Once the incident has been documented appropriately, where does the nurse send the blood transfusion bag?

Blood bank.

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit values. The nurse takes the client's temperature orally before hanging the blood transfusion and notes that it is 100.0° F. What should the nurse do next?

Call the healthcare provider. If the client has a temperature of 100.0° F or higher, the unit of blood should not be hung until the physician has been notified and had the opportunity to give further prescriptions.

A client with heart failure is being given furosemide (Lasix) and digoxin (Lanoxin). The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first?

Checking the result of laboratory testing for potassium on the sample drawn 3 hours ago.

A client is receiving parenteral nutrition (PN) with fat emulsion (lipids) piggybacked to the PN solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply.

Chills Headache Chest and back pain Nausea and Vomiting

A physician prescribes the administration of parenteral nutrition (PN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the PN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse immediately:

Clamps the PN infusion line.

A nurse has taught a client taking a methylxanthine bronchodilator about beverages that must be avoided. Which beverage choices by the client indicate to the nurse that the client needs further education? Select all that apply.

Cocoa, Coffee, Chocolate milk.

A nurse suspects that a client receiving parenteral nutrition (PN) through a central line has an air embolism. The nurse immediately positions the client on the:

Left side with the head lower than the feet.

A nurse is assessing a client who is being hospitalized with a diagnosis of pneumonia. The client's husband tells the nurse that the client is taking donepezil hydrochloride (Aricept). The nurse should ask the husband about the client's history of which disorder?

Dementia.

A client who needs to receive a blood transfusion has experienced a pruritic rash during previous transfusions. The client asks the nurse whether it is safe to receive the transfusion. Which of the following medications does the nurse remember will likely be prescribed before the transfusion?

Diphenhydramine (Benadryl).

The serum theophylline level of a client who is taking the medication (Theo-24) is 16 mcg/mL. On the basis of this result, the nurse will initially:

Document the normal value on the chart.

A nurse is teaching a client how to mix regular and NPH insulin in the same syringe. The nurse tells the client to:

Draw the regular insulin into the syringe first.

A nurse is caring for a client with a diagnosis of chronic renal failure who is receiving dialysis. Epoetin alfa (Epogen), to be administered subcutaneously, has been prescribed, and the nurse is drawing the medication from a single-use vial. The nurse should prepare the medication by:

Drawing up the medication and discarding the unused portion.

A home health nurse provides instructions to a client who is taking allopurinol (Zyloprim) for the treatment of gout. The nurse should tell the client to:

Drink at least 8 glasses of fluid every day.

The first bag of parenteral nutrition (PN) solution has arrived on the clinical unit for a client beginning this nutritional therapy. The solution is to be infused by way of a central line. Which of the following essential pieces of equipment does the nurse obtain before hanging the solution?

Electronic infusion device.

A nurse is providing dietary instructions to a client taking spironolactone (Aldactone). Which of the following foods does the nurse instruct the client are acceptable to consume? Select all that apply.

Rice Cereal Carrots

A client who is taking bupropion (Wellbutrin) in an attempt to stop smoking tells a nurse that he has been doubling the daily dose to make it easier to resist smoking. The nurse warns the client that doubling the daily dosage is dangerous. Of which adverse effect of the medication does the nurse warn the client?

Seizures.

Disulfiram (Antabuse) is prescribed for a client. Which questions does the nurse make a priority of asking the client before administering this medication? Select all that apply.

"When was your last drink of alcohol?" "Do you have a history of thyroid problems?"

A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN). The nurse notes moisture under the dressing covering the catheter insertion site. What does the nurse assess next?

Tightness of the tubing connections.

Cyclophosphamide has been prescribed for a client with a diagnosis of breast cancer, and the nurse is providing instructions to the client. The nurse should tell the client:

To increase fluid intake to 2000 mL to 3000 mL/day.

A nurse is providing instructions to a client regarding quinapril hydrochloride (Accupril). The nurse teaches the client:

To rise slowly from a lying to a sitting position.

A physician's prescription reads, "Clindamycin phosphate (Cleocin Phosphate) 0.3 g in 50 mL NS, to be administered IV over 30 minutes." The medication label reads, "Clindamycin phosphate (Cleocin Phosphate) 150 mg/mL." How many milliliters of medication does the nurse prepare to ensure that the correct dose is administered?

2

A nurse is developing a plan of care for a client, hospitalized with heart failure, who has a history of Parkinson disease and is taking benztropine mesylate (Cogentin) daily. Which intervention does the nurse identify as a priority in the plan?

Monitoring intake and output. Urine retention is a side effect of benztropine mesylate (Cogentin).

A client is receiving morphine sulfate for pain. Which action does the nurse identify as a priority in the plan of care for this client?

Monitoring the client's respiratory rate.

A client with rheumatoid arthritis is taking high doses of acetylsalicylic acid (aspirin, ASA). While assessing the client for aspirin toxicity, which question should the nurse ask the client?

"Do you have any ringing in the ears?"

A nurse instructs a client with myxedema about the dosage, method of administration, and side effects of levothyroxine sodium (Synthroid). Which statement by the client indicates an understanding of the nurse's instructions?

"I need to report any episodes of palpitations, chest pain, or dyspnea."

A nurse provides instructions to a client who will be taking furosemide (Lasix). Which of the following statements by the client indicates to the nurse that the client needs additional instruction?

"I should expect to have ringing in my ears."

Warfarin sodium (Coumadin) has been prescribed, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary?

"I won't take any over-the-counter medications except aspirin."

A physician prescribes 2000 mL of 5% dextrose and normal saline 0.45% for infusion over 24 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

21

A physician prescribes 1000 mL of normal saline 0.45% for infusion over 8 hours. The drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round your answer to the nearest whole number).

21.

A physician prescribes 1000 mL of 5% dextrose in water, to be infused over 24 hours. The drop factor is 60 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round your answer to the nearest whole number).

42

A nurse is caring for a group of adult clients on an acute care nursing unit. Which of the following clients does the nurse recognize as the least likely candidate for parenteral nutrition (PN)?

45-year-old client who has undergone repair of a hiatal hernia.

A nurse is making initials rounds on a group of assigned clients. Which of the following clients should the nurse see first?

A client whose PN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating.

Which clients does the nurse recognize as the most likely candidates for total parenteral nutrition (TPN)? Select all that apply.

A client with a severe exacerbation of ulcerative colitis. A client with severe sepsis. A client with pancreatitis.

A nurse is caring for a client with histoplasmosis who is receiving intravenous amphotericin B (Fungizone). What should the nurse do while the medication is being administered?

Monitor the client's urine output.

A client with HIV infection has been started on therapy with zidovudine (AZT, Retrovir). The nurse tells the client to report to the laboratory in 3 months for testing to detect adverse effects of the therapy. Which of the following laboratory tests is most important in light of the therapy that has been prescribed for this client?

Complete blood count (CBC)

A nurse discontinues infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which of the following actions does the nurse take next?

Contacting the healthcare provider.

Metoprolol (Lopressor) has been prescribed for a client with hypertension. For which common side effects of the medication does the nurse monitor the client? Select all that apply.

Fatigue. Weakness Impotence.

Carbamazepine (Tegretol) is prescribed for a client with trigeminal neuralgia. Which of the following side effects does the nurse instruct the client to report to the physician? Select all that apply.

Fever Sore throat Mouth sores.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. Which of the following assessment findings indicates to the nurse that the client is experiencing magnesium toxicity?

Sudden drop in fetal heart rate.

The nurse is preparing to change the solution bag and intravenous tubing of a client receiving parenteral nutrition (PN) through a left subclavian central venous line. Which essential action does the nurse ask the client to perform just before switching the tubing?

Take a deep breath and hold it.

A client is receiving heparin sodium by way of continuous IV infusion. For which adverse effects of the therapy does the nurse assess the client? Select all that apply.

Tarry stools Bleeding from the gums.

A client who has undergone adrenalectomy is prescribed prednisone. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

Tarry stools.

A client taking metronidazole (Flagyl) for the treatment of trichomoniasis vaginalis calls the clinic nurse to express concern because her urine has turned dark. The nurse should tell the client:

That darkening of the urine is a harmless side effect.

A client has been taking metoprolol (Lopressor, Toprol-XL). Which of the following findings indicates to the clinic nurse that the medication is effective?

The client's blood pressure has decreased.

A client who has been taking lisinopril (Prinivil) complains to the nurse of a persistent dry cough. The nurse tells the client that:

This is a side effect of therapy.

A physician's prescription for an adult client reads, "Potassium chloride 15 mEq by mouth." The label on the medication bottle reads, "20 mEq potassium chloride/15 mL." How many milliliters of KCl does the nurse prepare to ensure administration of the correct dose of medication? (Round your answer to the nearest whole number.)

11

At 1300, the nurse is documenting the receipt of a unit of packed blood cells at the hospital blood bank. The nurse calculates that the transfusion must be started by:

1330.

A nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. For how long does the nurse plan to stay with the client after the unit of blood is hung?

15 minutes.

At 1600 the nurse checks a client's parenteral nutrition (PN) infusion bag and finds 1100 mL remaining in the 3000-mL bag. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at:

1800.

A client with schizophrenia who has been taking an antipsychotic medication calls the clinic nurse and says, "I need to cancel my appointment with the psychiatrist again, because I still have this awful sore throat. It's so bad that my mouth has a sore." How does the nurse respond to the client?

"I think you need to come in for blood work today, because this may be a side effect of your medicine."

A client with heart failure being discharged home will be taking furosemide (Lasix). Which of the following statements by the client indicates to the nurse that the teaching has been effective?

"I'll weigh myself every day."

A client with a thoracic spinal cord injury is receiving dantrolene sodium (Dantrium). Which statement by the client indicates to the nurse that the client is experiencing an undesired effect of the medication?

"I'm feeling really drowsy."

A young female client with schizophrenia says to the nurse, "Since I started on Zyprexa [olanzapine] last year, I'm doing well in school and all, but I've gained so much weight, and it's really bothering me. What can I do about this?" Which response by the nurse would be therapeutic?

"Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?"

A physician prescribes an intramuscular dose of 200,000 units of penicillin G benzathine (Bicillin) for an adult client. The label on the 10-mL ampule sent from the pharmacy reads, "Penicillin G benzathine (Bicillin), 300,000 units/mL." How many milliliters of medication does the nurse prepares to ensure administration of the correct dose? (Round your answer to the nearest tenth.)

0.7

A client has a prescription for a unit of packed red blood cells (RBCs). Which of the following IV solutions should the nurse obtain to hang with the blood product at the client's bedside?

0.9% sodium chloride.

A physician's prescription reads, "Phenytoin (Dilantin) 0.1 g by mouth twice daily." The medication label indicates that the bottle contains 100-mg capsules. How many capsules does the nurse prepare for administration of one dose?

1

A nurse is monitoring a client who is receiving parenteral nutrition (PN). Which of the following signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication?

Nausea, thirst, and increased urine output.

Erythromycin is prescribed for a client with a respiratory tract infection. The nurse provides instructions to the client regarding the administration of the oral medication and tells the client to take the medication:

On an empty stomach. with a full glass of water

Phenelzine sulfate (Nardil) is being administered to a client with depression. The client suddenly complains of a severe frontally radiating occipital headache, neck stiffness and soreness, and vomiting. On further assessment, the client exhibits signs of hypertensive crisis. Which of the following medications should the nurse prepare to administer, anticipating that it will be prescribed as the antidote to treat phenelzine-induced hypertensive crisis?

Phentolamine.

A nurse notes that the site of a client's peripheral IV catheter is reddened, warm, painful, and slightly edematous in the area of the insertion site. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced:

Phlebitis of the vein.

Risperidone (Risperdal) is prescribed for a client with a diagnosis of schizophrenia. Which laboratory study does the nurse expect to see among the physician's prescriptions?

Platelet count.

Betaxolol (Betoptic) eye drops have been prescribed for the treatment of a client's glaucoma. The nurse tells the client to return to the clinic:

For measurement of blood pressure and apical pulse.

A nurse answers a call bell and finds that the parenteral nutrition (PN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which of the following actions should the nurse take first?

Hanging a solution of 10% dextrose in water.

A client is taking a folic acid supplement (Folate). Which of the following laboratory parameters does the nurse use to evaluate the effectiveness of this therapy? Select all that apply.

Hemoglobin. Hematocrit.

A client taking hydrochlorothiazide reports to the clinic for follow-up blood tests. For which side effect of the medication does the nurse monitor the client's laboratory results?

Hypokalemia.

A nurse is preparing a plan of care for a client with renal colic who is receiving meperidine hydrochloride (Demerol) for pain. Which side effects does the nurse make a note of needing to be alert to in the plan of care? Select all that apply.

Hypotension, Constipation, Urine retention, Respiratory depression.

A nurse is preparing a client for the insertion of a central intravenous line into the subclavian vein by the healthcare provider. The nurse places the client in which position

In a slight Trendelenburg position.

Fluoxetine hydrochloride (Prozac) is prescribed for a client, and the nurse provides instruction regarding the use of the medication. The nurse tells the client that it is best to take the medication:

In the morning.

A nurse is reading the medical record of a client receiving haloperidol (Haldol). The nurse notes that the physician has documented that the client is experiencing signs of akathisia. On the basis of the physician's note, which clinical manifestation would the nurse expect to find during assessment of the client?

Motor restlessness.

Baclofen (Lioresal) is prescribed for a client with a spinal cord injury who is experiencing muscle spasms. While providing instructions to the client, which of the following side effects does the nurse tell the client is possible?

Nasal congestion.

A nurse is caring for a client who has been taking acetazolamide (Diamox) for glaucoma. Which of the following, documented in the assessment data, indicates to the nurse that the client may be experiencing an adverse effect of the medication?

Jaundice.

A client with tuberculosis is being started on isoniazid (INH), and the nurse stresses the importance of returning to the clinic for follow-up blood testing. Which blood test will be performed?

Liver enzymes.

A client is receiving intravenous bleomycin sulfate. During administration of the chemotherapy, which of the following nursing assessments is of the highest priority?

Lung sounds

A client has just undergone insertion of a central venous catheter by the healthcare provider at the bedside. Which of the following results would the nurse be sure to check before initiating infusion of the IV solution that the healthcare provider has prescribed?

Portable chest x-ray.

Methylergonovine (Methergine) intramuscularly is prescribed for a postpartum client. Before administering the medication, the nurse explains to the client that the medication will:

Prevent postpartum bleeding.

A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of parenteral nutrition (PN), a solution containing 25% glucose. Which of the following actions should be taken by the nurse?

Questioning the healthcare provider about the prescription.

A nurse has just hung a transfusion of packed red blood cells and stayed with the client for the appropriate amount of time. Before leaving the room, the nurse tells the client that it is most important to immediately report which specific sign if it occurs? Select all that apply.

Rash Chills Backache.

A client has a prescription for short-term therapy with enoxaparin (Lovenox). The nurse explains to the client that this medication is being prescribed to:

Reduce the risk of deep vein thrombosis.

A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the insertion site. What should the nurse do first?

Remove the IV.

A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse first:

Removes the IV catheter.

A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. Which of the following actions should the nurse take? Select all that apply.

Removing the IV catheter at that site Applying warm, moist compresses to the IV site Notifying the healthcare provider about the finding.

A client receiving parenteral nutrition (PN) requires fat emulsion (lipids), which will be piggybacked to the PN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are floating at the top of the solution. Which of these actions should the nurse take?

Requesting a new bottle from the pharmacy.

A nurse is monitoring a client who is receiving a continuous intravenous infusion of morphine sulfate. Which finding should cause the nurse to contact the physician?

Respiratory rate of 10 breaths/min.

A nurse is to administer a dose of digoxin (Lanoxin) to a client with atrial fibrillation. The client has a potassium level of 4.6 mEq/L. The nurse determines that the dose:

Should be administered as prescribed.

A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which of the following actions should the nurse take first?

Shutting off the IV infusion.

A nurse has a written prescription to remove an intravenous (IV) line. Which of the following items should the nurse obtain from the unit supply area for use in applying pressure to the site after removing the IV catheter?

Sterile 2 × 2 gauze.

The nurse determines that the client is exhibiting signs of a hemolytic transfusion reaction while receiving a blood transfusion. Place the actions the nurse should perform in the correct order, with number 1 the first action and number 5 the last action:

The correct order is: 1. Stopping the infusion of blood 2. Hanging an IV bag of normal saline solution (NS) at a keep-vein-open (KVO) rate 3. Notifying the healthcare provider 4. Obtaining vital signs/oxygen saturation 5. Documenting the findings.

A client with newly diagnosed angina pectoris has taken 2 sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client complains of a headache. The nurse tells the client that:

This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen (Tylenol).

Zidovudine (AZT) is prescribed for an adult client with HIV infection. The nurse, while providing instructions to the client, should tell the client:

To space the doses evenly around the clock.

A nurse is preparing a plan of care for a pregnant client who will be given oxytocin (Pitocin) to induce labor. Which of the following occurrences does the nurse include in the plan of care as a reason for immediate discontinuation of the oxytocin infusion?

Uterine hyperstimulation.

Intravenous tobramycin sulfate (Tobrex) is prescribed for a client with a respiratory tract infection. For which of the following symptoms, indicative of an adverse effect, does the nurse monitor the client?

Vertigo.

A nurse has obtained a unit of blood from the blood bank and properly checked the blood bag with another nurse. Which of the following parameters does the nurse assess just before hanging the transfusion?

Vital signs.

A home care nurse has been assigned a client who has been discharged home with a prescription for parenteral nutrition (PN). Which of the following parameters does the nurse plan to check at each visit as a means of identifying complications of the PN therapy? Select all that apply.

Weight, Glucose test, Temperature.