Medication Administration in a Medical-Surgical Setting Comprehensive Examination

The client diagnosed with multiple sclerosis (MS) is receiving baclofen. Which information should the nurse teach the client and family? 1. The importance of tapering off when discontinuing the medication. 2. Baclofen may cause diarrhea, so the client should take antidiarrheal medication. 3. The client should not be allowed to drive alone while taking this medication. 4. The client should have follow-up visits to obtain a monthly white blood cell count.

Answer: 1 1. Abrupt discontinuation of baclofen (Lioresal), a muscle relaxant, is associated with hallucinations, paranoia, and seizures. 2. This medication causes constipation and urinary retention. 3. The client should not be allowed to drive at all when taking this medication because it causes drowsiness, and the spasticity of MS makes driving dangerous for the client. 4. White blood cell levels do not need to be monitored because the baclofen (Lioresal), a muscle relaxant, does not cause bone marrow suppression.

The client diagnosed with diabetes mellitus type 2 is scheduled for bowel resection in the morning. Which medication should the nurse question administering to the client? 1. Ticlopidine. 2. Ticarcillin. 3. Pioglitazone. 4. Bisacodyl.

Answer: 1 1. Any medication that will prolong bleeding as a platelet aggregate inhibitor does, including ticlopidine (Ticlid), should not be administered to the client for at least 2 to 3 days before surgery. 2. The nurse should not question administering Ticarcillin (Timentin), an extended-spectrum antibiotic before surgery, especially not before gastrointestinal surgery. 3. Pioglitazone (Actos), a thiazolidinedione, is a medication for type 2 diabetes and should be administered the day before the surgery. 4. The client will be receiving medications to evacuate the bowel. Bisacodyl (Dulcolax) is a cathartic laxative.

The HCP ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with MI. Which statement best explains the rationale for administering this medication to this client? 1. It will help prevent the development of congestive heart failure. 2. This medication will help decrease the client's blood pressure. 3. ACE inhibitors increase the contractility of the heart muscle. 4. They will help decrease the development of atherosclerosis.

Answer: 1 1. Attempting to prevent CHF is the rationale for administering ACE inhibitors to clients diagnosed with MIs. This medication is administered for a variety of medical diagnoses, such as heart failure and stroke, and to help prevent diabetic nephropathy. 2. ACE inhibitors are prescribed to help decrease blood pressure, but the stem states the client has had an MI, not essential hypertension. 3. Cardiac glycosides such as digoxin, not ACE inhibitors, increase the contractility of the heart. 4. Antilipidemics, not ACE inhibitors, help decrease the development of atherosclerosis.

The client diagnosed with type 2 diabetes mellitus is prescribed glyburide. Which statement indicates the client understands the medication teaching? 1. "I should carry some hard candy when I go walking." 2. "I must take my insulin injection every morning." 3. "There are no side effects I need to worry about." 4. "This medication will make my muscles absorb insulin."

Answer: 1 1. Glyburide (Diabeta), a sulfonylurea, stimulates the pancreas to secrete insulin. Therefore, the client is at risk for developing hypoglycemic reactions, especially during exercise. 2. This is an oral hypoglycemic medication. 3. There are side effects to every medication; glyburide (Diabeta), a sulfonylurea, can cause hypoglycemia. 4. The medication stimulates the pancreas to produce more insulin, but it does not affect the muscles' absorption of glucose.

The client is receiving a loop diuretic for congestive heart failure. Which medication would the nurse expect the client to be receiving while taking this medication? 1. A potassium supplement. 2. A cardiac glycoside. 3. An ACE inhibitor. 4. A potassium cation.

Answer: 1 1. Loop diuretics cause loss of potassium in the urine output; therefore, the client should be receiving potassium supplements. Hypokalemia can lead to life-threatening cardiac dysrhythmias. 2. A cardiac glycoside, digoxin, is administered for congestive heart failure, but it is not necessary when administering a loop diuretic. 3. An ACE inhibitor is not prescribed along with a loop diuretic. It may be ordered for congestive heart failure. 4. A potassium cation, Kayexalate, is ordered to remove potassium through the bowel for clients diagnosed with hyperkalemia.

The nurse is assessing the older client first thing in the morning. The client is confused and sleepy. Which intervention should the nurse implement first? 1. Determine if the client received a sedative last night. 2. Allow the client to continue to sleep and do not disturb. 3. Encourage the client to ambulate in the room with assistance. 4. Notify the health-care provider about the client's status.

Answer: 1 1. Many times, especially with older clients, sedatives extend the desired effects longer than expected; therefore, the nurse should check to see if the client received any sleeping medication. 2. The nurse should assess why the client is sleepy and then allow the client to sleep if the sleepiness is a result of receiving a sedative the previous night. 3. If an older client is confused and drowsy, the client should not be allowed to ambulate, even if assistance is being provided, because of safety issues. 4. The nurse must determine if this is an expected occurrence or a decrease in neurological function before notifying the HCP.

The client diagnosed with essential hypertension calls the clinic and tells the nurse she needs something for the flu. Which information should the nurse tell the client? 1. OTC medications for the flu should not be taken because of your hypertension. 2. If OTC medications do not relieve symptoms within 3 days, contact the HCP. 3. Tell the client to ask the pharmacist to recommend an OTC medication for the flu. 4. Make an appointment for the client to receive the influenza vaccine.

Answer: 1 1. OTC decongestant medications used for the flu cause vasoconstriction of the blood vessels, which would increase the client's hypertension and therefore should be avoided. The client should let the flu run its course. 2. OTC medications should not be taken by the client diagnosed with essential hypertension. 3. The nurse should provide the information to the client about what medications to take and should not refer the client to the pharmacist. 4. It is too late for the flu vaccine because the client is already ill with the flu.

The client is admitted to the burn unit and prescribed pantoprazole. Which statement best supports the scientific rationale for administering this medication to a client diagnosed with a severe burn? 1. This medication will help prevent a stress ulcer. 2. This medication will help prevent systemic infections. 3. This medication will provide continuous vasoconstriction. 4. This medication will stimulate new skin growth.

Answer: 1 1. Pantoprazole (Protonix), a proton pump inhibitor (PPI), decreases gastric secretion and is prescribed for clients to prevent Curling's stress ulcer. PPIs are ordered for most clients in the intensive care department, not just clients diagnosed with burns. 2. PPIs do not treat infections; antibiotics treat infections. 3. Pantoprazole (Protonix), a PPI, does not cause continuous constriction. Dopamine might do this. 4. A positive nitrogen balance accomplished through nutritional interventions will help promote tissue regeneration.

The nurse is preparing to administer phenytoin, 100 mg intravenous push, to the client diagnosed with a head injury with an IV of D5W at 50 mL/hr. Which intervention should the nurse implement? 1. Flush the IV tubing before and after with normal saline. 2. Administer the medication if the phenytoin level is 22 mcg/mL. 3. Push the phenytoin intravenously rapidly over 1 minute. 4. Expect the intravenous tubing to turn cloudy when infusing the medication.

Answer: 1 1. Phenytoin (Dilantin) will crystallize in the tubing and is not compatible with any IV fluid except normal saline. The IV tubing must be flushed before the medication is administered. 2. The therapeutic phenytoin (Dilantin) level is 10 to 20 mcg/mL; therefore, this is a toxic level. 3. The medication is administered undiluted at a rate not to exceed 50 mg/min. 4. If the tubing turns cloudy, it means it is not compatible, and the nurse must stop the IVP immediately and discontinue the IV.

The client is diagnosed with tuberculosis and prescribed rifampin and isoniazid (INH). Which instruction is most important for the public health nurse to discuss with the client? 1. The client will have to take the medications for 6 to 12 months. 2. The client will have to stay in isolation as long as medications are taken. 3. Explain the client cannot eat any type of pork products while taking the medication. 4. The urine may turn turquoise in color, but this is an expected occurrence and harmless.

Answer: 1 1. Rifampin and isoniazid (INH), both antituberculosis medications, are taken for 6 months to 1 year and often in combination with two other medications. Directly observed therapy (DOT) is recommended to ensure medication compliance because TB is a public health issue and the most common cause of infectious disease-related mortality worldwide. 2. The client is in isolation until three consecutive early-morning sputum cultures are negative, which is usually in about 2 to 4 weeks. 3. Pork products do not interact with rifampin and isoniazid (INH), both antituberculosis medications. 4. The client's urine and all body fluids may turn orange from the rifampin.

The client is reporting nausea, and the nurse administers promethazine, IM. Which intervention has priority for this client after administering this medication? 1. Instruct the client to call the nurse before getting out of bed. 2. Evaluate the effectiveness of the medication. 3. Assess the client's abdomen and bowel sounds. 4. Tell the client not to eat or drink for at least 1 hour.

Answer: 1 1. Safety is a priority when administering the antiemetic promethazine (Phenergan) because it causes sedative-like effects. 2. Evaluation is not a priority over safety. 3. The nurse should have assessed the client's GI system before administering the antiemetic, not after. 4. Withholding fluids and food is an appropriate intervention to help prevent emesis, but it is not a priority over safety after administering promethazine (Phenergan).

The client has arterial blood gases populated in the ABG chart below. Which medication would the nurse prepare to administer based on the results? - pH: 7.19 - PCO2: 33 - HCO3: 19 - PAO2: 95 1. Intravenous sodium bicarbonate. 2. Oxygen via nasal cannula. 3. Epinephrine intravenous push. 4. Magnesium hydroxide orally.

Answer: 1 1. The ABG results indicate metabolic acidosis, and the treatment of choice is sodium bicarbonate. 2. Oxygen is the treatment of choice for respiratory acidosis. 3. Epinephrine is administered in a code situation. 4. This is milk of magnesia, which is an antacid and laxative, but it is not the treatment for metabolic acidosis.

For which client would the nurse question administering mannitol? 1. The client diagnosed with 4+ pitting pedal edema. 2. The client diagnosed with decorticate posturing. 3. The client diagnosed with widening pulse pressure. 4. The client diagnosed with a positive doll's eye test.

Answer: 1 1. The client diagnosed with pitting pedal edema is in fluid volume overload, which should make the nurse question administering an osmotic diuretic because the osmotic diuretic mannitol (Osmitrol) will pull more fluid from the tissues into the circulatory system, causing further fluid volume overload. 2. An osmotic diuretic is administered for increased intracranial pressure; therefore, a client exhibiting decorticate posturing would need this medication. 3. A widening pulse pressure indicates increased intracranial pressure; therefore, the client needs the osmotic diuretic mannitol (Osmitrol). 4. The doll's eye test indicates increased intracranial pressure, which is why the HCP would prescribe the osmotic diuretic mannitol (Osmitrol).

The client diagnosed with Parkinson's disease is taking levodopa and is experiencing an "on-off" phenomenon. Which action should the nurse take regarding this medication? 1. Document the occurrence and take no action. 2. Request the HCP to increase the dose of medication. 3. Discuss the client's imminent death as a result of this complication. 4. Explain this is a desired effect of the medication.

Answer: 1 1. The loss of effect of the medication occurs near the end of a dosing interval and indicates the plasma drug level has declined to subtherapeutic value. This is an expected occurrence with levodopa (L-dopa) and the chronic nature of the disease. 2. Increasing the dose increases the peripheral action of levodopa (L-dopa) on the heart and vessels. Because 75% of the drug never crosses the blood-brain barrier, the dose may not be increased. 3. This effect does not mean the client is dying. It means the levodopa (L-dopa) is wearing off. 4. This is not the desired effect of the medication.

The client is receiving a continuous intravenous infusion of heparin. Based on the most recent laboratory data: - PT: 13.2 - PTT: 72 - INR: 1.3 Which action should the nurse implement? 1. Continue to monitor the infusion. 2. Prepare to administer protamine sulfate. 3. Have the laboratory reconfirm the results. 4. Assess the client for bleeding.

Answer: 1 1. The therapeutic heparin, an anticoagulant, level is 1.5 to 2 times the control, which is 58 to 78; therefore, a PTT of 72 is within therapeutic range so the nurse should continue to monitor the infusion. PT and INR are used to monitor the oral anticoagulant warfarin (Coumadin). 2. Protamine sulfate is the antidote for heparin toxicity, but the client is in the therapeutic range. 3. There is no need for the laboratory to reconfirm the results. 4. The nurse would not need to assess for bleeding because the results are within the therapeutic range.

The 38-year-old client diagnosed with chronic asthma is prescribed a leukotriene receptor antagonist. Which is the scientific rationale for administering this medication? 1. This medication is used prophylactically to control asthma. 2. This medication will cure the client's chronic asthma. 3. It will stabilize mast cell activities and reduce asthma attacks. 4. It will cause the bronchioles to dilate and increase the airway.

Answer: 1 1. This medication decreases inflammation by stabilizing the leukotrienes in the lung, which initiate an asthma attack. 2. Children may outgrow asthma attacks, whereas adult asthmatics can control their disease, but there is no cure for asthma at this time. 3. This is the scientific rationale for mast cell inhibitors. 4. This is the scientific rationale for bronchodilators.

The client diagnosed with osteoarthritis is prescribed an NSAID. Which intervention should the nurse implement? 1. Time the medication to be given with meals. 2. Notify the HCP if abdominal striae develop. 3. Do not administer if the oral temperature is greater than 102°F. 4. Monitor liver function tests and renal studies.

Answer: 1 1. This medication is harsh on the lining of the stomach and should be taken with meals. 2. Abdominal striae occur with steroids, not NSAIDs. 3. The temperature does not affect the administration of this medication. NSAIDs would be prescribed for fever. 4. The liver and kidneys are responsible for metabolizing and excreting all medications, but the tests are not routinely monitored for NSAIDs.

The employee health RN is observing a student nurse administer a Mantoux tuberculin skin test with purified protein derivative (PPD) to a new employee. Which behavior would warrant immediate intervention by the employee health nurse? 1. The student nurse inserts the needle at a 45-degree angle. 2. The student nurse cleanses the forearm with alcohol. 3. The student nurse circles the injection site with ink. 4. The student nurse instructs the employee to return in 3 days.

Answer: 1 1. This medication should be administered intradermally with the needle barely inserted under the skin so a wheal (bubble) forms after the injection. 2. Cleansing the forearm with an alcohol swab is standard procedure and would not warrant immediate intervention. 3. Circling the site is an appropriate intervention so, when the skin test is read and no reaction is occurring, the nurse will be able to document a negative skin test reading. 4. The skin test is read in 3 days to determine the results.

The client diagnosed with arthritis is self-medicating with acetylsalicylic acid. Which complication should the nurse discuss with the client? 1. Tinnitus. 2. Diarrhea. 3. Tetany. 4. Paresthesia.

Answer: 1 1. Tinnitus, ringing in the ears, is a sign of ASA (aspirin) toxicity and needs to be reported to the HCP; the aspirin should be stopped immediately. 2. Diarrhea is a complication of many medications but not with aspirin. 3. Tetany is muscle twitching secondary to hypocalcemia. 4. ASA (aspirin) does not cause paresthesia, which is numbness or tingling.

The client diagnosed with bipolar disorder has been taking valproic acid for 4 months. Which assessment data would warrant the medication being discontinued? 1. The client's eyes are yellow. 2. The client has mood swings. 3. The client's BP is 164/94. 4. The client's serum level is 75 mcg/mL.

Answer: 1 1. Yellow eyes would indicate the client is experiencing some type of hepatic toxicity, which would warrant the valproic acid (Depakote), an anticonvulsant, being discontinued immediately. During the first few months of treatment, the client is closely monitored for hepatic toxicity because deaths have occurred. 2. The medication dose may need to be increased, but valproic acid (Depakote), an anticonvulsant, is administered to prevent the mood swings. 3. The BP is slightly elevated, but it is not related to the medication. 4. The therapeutic serum valproic acid level is 50 to 125 mcg/mL; therefore, the client is within the therapeutic range.

The client diagnosed with angina must receive a 2-inch nitroglycerin paste application. Which interventions should the nurse implement? Select all that apply. 1. Wear gloves when administering. 2. Remove the old nitroglycerin paste paper. 3. Apply the paper on a hairy spot. 4. Put medication only on the legs. 5. Report any headache to the HCP.

Answer: 1, 2 1. If the nurse does not wear gloves, the nurse can absorb the nitroglycerin paste (Nitro-Bid) and get a headache. 2. The old nitroglycerin paste must be removed because it could cause an overdose of the medication. 3. The paper should be applied to a clean, dry, hairless area. 4. The nitroglycerin paste (Nitro-Bid) can be placed on the chest, arms, back, or legs. 5. A headache is a common side effect and should not be reported to HCP.

The client is showing ventricular ectopy, and the HCP orders amiodarone intravenously. Which interventions should the nurse implement? Select all that apply. 1. Monitor telemetry continuously. 2. Assess the client's respiratory status. 3. Evaluate the client's liver function studies. 4. Confirm the original order with another nurse. 5. Prepare to defibrillate the client at 200 joules.

Answer: 1, 2, 3, 4 1. Telemetry should be monitored during amiodarone (Cordarone) therapy to ensure the client does not develop worsening of dysrhythmias. 2. The client taking amiodarone (Cordarone) is at risk for pulmonary toxicity and developing adult respiratory distress syndrome (ARDS); therefore, the nurse should monitor the client's respiratory status. 3. When the client is receiving medications intravenously, monitoring the liver and renal function is appropriate; amiodarone (Cordarone) causes hepatomegaly. 4. Intravenous vasoactive medications are inherently dangerous; fatalities have occurred from amiodarone (Cordarone), so the nurse confirming the order with another nurse is appropriate. 5. The nurse should never defibrillate a client with a heartbeat, and nothing in the stem states the client is in ventricular fibrillation.

The nurse is preparing to administer the initial dose of an antibiotic in the emergency department. Which interventions should the nurse implement? Select all that apply. 1. Assess for drug allergies. 2. Collect needed specimens for culture. 3. Check the client's armband. 4. Ask the client for a birth date. 5. Draw peak and trough levels.

Answer: 1, 2, 3, 4 1. The nurse should always assess for allergies, but especially when administering antibiotics, which are notorious for allergic reactions. 2. If specimens are not obtained for C&S before administering the first dose of antibiotic, the results will be skewed. 3. One of the five rights is to administer the medication to the "right client." Checking the armband on the client with the MAR and medication is a way to ensure this. 4. The 2005 Joint Commission standards require two forms of identification before administering medications. The client's armband and medical record number provide one form of identifying information, and the client's birthday is the second form of identification in most health-care facilities. This is a nationwide emphasis to help prevent medication errors. 5. The stem does not state it is an aminoglycoside antibiotic, and it is the initial dose, which means there is no medication in the system even if it were an aminoglycoside antibiotic.

The female client diagnosed with Trichomonas vaginalis is prescribed metronidazole. Which statement indicates the client understands the discharge teaching? Select all that apply. 1. "I will not be able to drink any alcohol while taking this drug." 2. "My boyfriend will need to take this same medication." 3. "I cannot transmit the disease through oral sex." 4. "I must make sure I take all the pills no matter how I feel." 5. "I should call my doctor if I get a rash."

Answer: 1, 2, 4, 5 1. Alcohol creates a disulfiram-like reaction to the metronidazole (Flagyl), an antibiotic and antiprotozoal agent, which causes severe nausea, vomiting, and extreme hypertension. 2. Trichomonas vaginalis is an asymptomatic sexually transmitted disease in males. If the male partner is not simultaneously treated, then he can reinfect the female. 3. This sexually transmitted infection can be transmitted via oral routes. 4. This is a concept that must be taught to all clients taking antibiotics: Take all the medications as prescribed. 5. Metronidazole can, in rare cases, cause Stevens-Johnson syndrome. The client should notify the HCP for the appearance of a rash.

The client diagnosed with epilepsy is prescribed carbamazepine. Which discharge instruction should the nurse include in the teaching? Select all that apply. 1. Wear SPF 30 sunscreen when outside. 2. Obtain regular serum drug levels. 3. Be sure to floss teeth daily. 4. Instruct the client to take tub baths only. 5. Avoid grapefruit and grapefruit juice.

Answer: 1, 2, 5 1. Carbamazepine (Tegretol), an anticonvulsant, is photosensitive, and the client must wear SPF of at least 30 to be protected. 2. Carbamazepine (Tegretol), an anticonvulsant medication, has a therapeutic level that must be maintained to help prevent seizures. The therapeutic range is from 4 to 12 mcg/mL (Vallerand & Sanoski, 2017). 3. Dilantin, another anticonvulsant, causes hyperplastic gingivitis, but carbamazepine does not. 4. The client diagnosed with a seizure disorder should only take showers because, if a seizure occurs in the bathtub, the client could drown. 5. Grapefruit and grapefruit juice can increase the amount of carbamazepine absorbed by the body, increasing side effects.

The male client is self-medicating with cimetidine. Which side effects can occur while taking this medication? Select all that apply. 1. Melena. 2. Gynecomastia. 3. Pyrosis. 4. Eructation. 5. Myalgia.

Answer: 1, 2, 5 1. Melena is a black, tarry stool, which could indicate an adverse reaction to this medication. 2. Gynecomastia, or breast development in men, is a complication of the H-2 antagonist cimetidine (Tagamet). 3. Pyrosis, or heartburn, is why the client would be taking this medication and not a side effect. 4. Eructation, or belching, is not a side effect or complication of the H-2 antagonist cimetidine (Tagamet). 5. Myalgia is mild to severe muscle aches and pain and can be a side effect of the H-2 antagonist cimetidine (Tagamet).

The nurse is administering digoxin to the client diagnosed with congestive heart failure. Which interventions should the nurse implement? Select all that apply. 1. Check the apical heart rate for 1 full minute. 2. Monitor the client's serum sodium level. 3. Teach the client how to take a radial pulse. 4. Evaluate the client's serum digoxin level. 5. Assess the client for buffalo hump and moon face.

Answer: 1, 3, 4 1. If the apical heart rate is less than 60, the nurse should question administering digoxin, a cardiac glycoside. 2. The client's potassium level, not the sodium level, should be monitored. 3. The client should be taught to monitor the radial pulse at home and not to take the medication if the pulse is less than 60 because digoxin, a cardiac glycoside, will further decrease the heart rate. 4. The digoxin level should be between 0.5 and 2 ng/mL to be therapeutic. 5. The client diagnosed with digoxin toxicity would complain of anorexia, nausea, and yellow haze; buffalo hump and moon face would be assessed for the client taking prednisone, a glucocorticoid.

The client diagnosed with coronary artery disease is prescribed atorvastatin to help decrease the client's cholesterol level. Which interventions should the nurse discuss with the client? Select all that apply. 1. The client should eat a low-cholesterol, low-fat diet. 2. The client should take this medication with each meal. 3. The client should take this medication in the evening. 4. The client should monitor daily cholesterol levels. 5. The client should take this medication at the same time each day.

Answer: 1, 5 1. This diet is recommended for clients diagnosed with coronary artery disease. 2. This medication is taken once a day in the evening. 3. Atorvastatin (Lipitor) can be taken at any time of day. Other HMG-CoA reductase inhibitors such as fluvastatin (Lescol), pravastatin (Pravachol), and simvastatin (Zocor) must be taken at night to enhance the enzymes that metabolize cholesterol. 4. There is no machine to test daily cholesterol levels. The cholesterol level is checked every 3 to 6 months. 5. Atorvastatin (Lipitor) can be taken at any time of the day, but the client should be instructed to take the medication at the same time each day.

The nurse is hanging 1,000 mL of IV fluids to run for 8 hours. The intravenous tubing is a micro-drip. How many drops per minute (gtt/min) should the IV rate be set? gtt/min

Answer: 125 gtt/min A micro-drip is 60 gtt/mL. The formula for this dosage problem is as follows: 1000 mL × 60 = 60,000 = 125 gtt/min 480 min 480

The 54-year-old female client diagnosed with severe menopausal clinical manifestations is prescribed hormone replacement therapy (HRT). Which secondary health screening activity should the nurse recommend for HRT? 1. A Pap smear every 6 months. 2. A yearly mammogram. 3. A bone density test every 3 months. 4. A serum calcium level monthly.

Answer: 2 1. A Pap smear is usually done yearly and is used to detect cervical cancer; HRT does not increase the risk. 2. The risk of developing breast cancer increases when the client is receiving HRT. 3. A bone density test is used to detect osteoporosis, and HRT improves bone density. 4. Calcium levels are not affected by HRT.

The older male client is in a long-term care facility. If the client does not have a daily bowel movement in the morning he requests a cathartic, bisacodyl. Which action is most important for the nurse to take? 1. Ensure the client gets a cathartic daily. 2. Discuss the complications of a daily cathartic. 3. Encourage the client to increase fiber in the diet. 4. Refuse to administer the medication to the client.

Answer: 2 1. A daily cathartic is a colonic stimulant, which results in dependency and a narrowing of the lumen of the colon, which increases constipation. 2. Although the client may think a medication for bowel movements is necessary, the nurse should teach the client that bisacodyl (Dulcolax) can cause serious complications, such as dependency and narrowing of the colon. 3. Fiber will help increase the roughage, which may help prevent constipation, but the most important action is to empower the client to make informed decisions about medications. 4. The nurse should not refuse to administer the medication; the nurse should talk to the client and, if needed, the HCP before administering the bisacodyl (Dulcolax).

The client is receiving enalapril. When would the nurse question administering this medication? 1. The client is not receiving potassium supplements. 2. The client reports a persistent irritating cough. 3. The blood pressure for two consecutive readings is 110/70. 4. The client's urinary output is 400 mL for the last 8 hours.

Answer: 2 1. ACE inhibitors may increase potassium levels. The client should avoid potassium salt substitutes and supplements; therefore, the nurse would not question the fact the client is not receiving potassium supplements. 2. An adverse effect of ACE inhibitors, including enalapril (Vasotec), is the possibility of a persistent irritating cough, which might precipitate the HCP's changing the client's medication. 3. This blood pressure indicates the ACE inhibitor enalapril (Vasotec), is effective. 4. The urinary output of 30 mL/hr indicates the kidneys are functioning properly.

The nurse is caring for an older client 8 hours postoperative hip replacement who is reporting incisional pain. Which intervention is a priority for this client? 1. Assist the client in sitting in the bedside chair. 2. Initiate pain medication at the lowest dose. 3. Assess the client's pupil size and accommodation. 4. Monitor the client's urinary output hourly.

Answer: 2 1. At 8 hours postoperative, the client should be on bedrest, and moving the client to a chair will not help the incisional pain and could cause hip dislocation. 2. Normal developmental changes in the organs of older clients, especially the kidneys and liver, result in lower doses of pain medication needed to achieve therapeutic levels. 3. This is a neurological assessment, which is not pertinent to the extremity assessment. 4. The urinary output would not affect the administration of pain medication.

The nurse is administering carbidopa and levodopa to the client. Which assessment should the nurse perform to determine if the medication is effective? 1. Assess the client's muscle strength. 2. Assess for cogwheel rigidity. 3. Assess the carbidopa serum level. 4. Assess the client's blood pressure.

Answer: 2 1. Carbidopa and levodopa (Sinemet) does not affect the client's muscle strength; it affects the smoothness of muscle movement. 2. Cogwheel rigidity (jerky, uneven movements when moving a limb) is a symptom of Parkinson's disease, and if the client is not experiencing this rigidity, then the carbidopa and levodopa (Sinemet) is effective. 3. There is no such thing as a carbidopa therapeutic level. The client's clinical manifestations determine the effectiveness of the medication. 4. The client's blood pressure should be assessed to determine if the client is having hypotension, which is a side effect of carbidopa and levodopa (Sinemet), but this does not determine the effectiveness of the medication.

The nurse is reviewing laboratory values for the female client diagnosed with cancer. Based on the laboratory report, which biologic response modifier would the nurse anticipate administering to the client? - RBCs: 4.11 - Hgb: 12.2 - Hct: 37 - WBCs: 2 - Platelets: 160 1. Interferon. 2. Filgrastim. 3. Oprelvekin. 4. Epoetin alfa.

Answer: 2 1. Interferon is administered to treat hepatitis and some cancers, but it does not stimulate the bone marrow. 2. Filgrastim (Neupogen) is a granulocyte-stimulating factor that stimulates the bone marrow to produce white blood cells (WBCs), which this client needs because the normal WBC count is 4.5 to 11.1 × 103/microL. 3. Oprelvekin (Neumega) stimulates the production of platelets, but the client's platelet count of 160 is normal (100 to 400 × 103/microL). 4. Epoetin alfa (Procrit) stimulates the production of red blood cells and hemoglobin, but a hemoglobin of 12.2 is normal for a woman (11.7 to 15.5 g/dL).

The client is diagnosed with pernicious anemia. Which HCP order should the nurse anticipate in treating this condition? 1. Subcutaneous iron dextran. 2. Intramuscular vitamin B12. 3. Intravenous folic acid. 4. Oral thiamine medication.

Answer: 2 1. Iron dextran is administered for iron-deficiency anemia intravenously or intramuscularly, not subcutaneously. 2. Vitamin B12 is administered for pernicious anemia because there is insufficient intrinsic factor produced by the rugae in the stomach to be able to absorb and use vitamin B12 from food sources. 3. Folic acid is administered orally or intravenously for folic acid deficiency, which is usually associated with chronic alcoholism. 4. Thiamine is administered intravenously in high doses to clients detoxifying from chronic alcoholism to prevent rebound nervous system dysfunction.

The nurse is evaluating the client's home medications and notes the client diagnosed with angina is taking an antidepressant. Which intervention should the nurse implement because the client is taking this medication? 1. Ask the client if there is a plan for suicide. 2. Assess the client's depression on a 1-to-10 scale. 3. Explain this medication cannot be taken because of angina. 4. Request a referral to the hospital psychologist.

Answer: 2 1. Just because a client is taking an antidepressant does not mean the client is suicidal. 2. The nurse should determine if the client is in a depressed state or if the medication is effective, so the nurse should ask the client to rate the depression on a 1-to-10 scale, with 1 being no depression and 10 being the most depressed. 3. Antidepressants must be tapered off because of rebound depression. 4. The client taking an antidepressant medication does not automatically need a referral to a psychologist.

The nurse is preparing to administer 37.5 mg of meperidine IM to a client reporting pain. The medication comes in a 50-mg/mL vial. Which action should the nurse implement? 1. Notify the pharmacist to bring the correct vial. 2. Have another nurse verify the wastage of medication. 3. Administer 1 mL of medication to the client. 4. Request the HCP to increase the client's dose.

Answer: 2 1. Medication does not always come in the exact amount of the HCP's order. 2. Because meperidine (Demerol) is a narcotic, the nurse preparing the medication must have someone to verify and document the wastage of 12.5 mg of the Demerol. 3. This would be a medication error because the order is for 37.5 mg, not 50 mg. 4. This would not be an appropriate intervention. The nurse can safely and accurately administer the prescribed meperidine (Demerol) dose to the client. If the pain is not controlled with the amount, then the HCP should be notified.

The client recently has had a myocardial infarction (MI). Which medication should the nurse anticipate the health-care provider (HCP) recommending to prevent another heart attack? 1. Nonsteroidal anti-inflammatory drug. 2. Low-dose acetylsalicylic acid. 3. An anticoagulant medication. 4. An iron supplement.

Answer: 2 1. NSAIDs are recommended for inflammatory disorders and to relieve mild to moderate pain. 2. A daily, low dose of acetylsalicylic acid (aspirin) is an antiplatelet that prevents platelet aggregation. 3. Anticoagulants are prescribed for clients diagnosed with a high risk for clot formation. 4. Iron supplements are recommended for clients diagnosed with iron-deficiency anemia.

The client diagnosed with migraine headaches is prescribed propranolol for prophylaxis. Which information should the nurse teach the client? 1. Instruct client to take the medication at the first sign of a headache. 2. Teach the client to take a radial pulse for 1 minute. 3. Explain this drug may make the client thirsty and have a dry mouth. 4. Discuss the need to increase artificial light in the home.

Answer: 2 1. Propranolol is taken prophylactically, which means the client should take the medication routinely whether the client has a headache or not. 2. Beta blockers decrease the heart rate. If the radial pulse is less than 60 bpm, the client should hold the propranolol (Inderal), a beta blocker, and notify the HCP. 3. Propranolol (Inderal), a beta blocker, will mask tachycardia in clients diagnosed with diabetes, an early symptom of hypoglycemia. Thirst and dry mouth are clinical manifestations of hyperglycemia, but this client does not have diabetes. 4. Beta blockers do not affect the client's visual acuity; therefore, a change in light is not necessary.

The client is receiving fibrinolytic therapy (thrombolytic therapy) for a diagnosed MI. Which assessment data indicate the therapy is successful? 1. The client's ST segment is becoming more depressed. 2. The client is exhibiting reperfusion dysrhythmias. 3. The client's cardiac isoenzyme CK-MB is not elevated. 4. The client's platelet count is increased 2 hours post-MI.

Answer: 2 1. The ST segment becoming more depressed indicates a worsening of the oxygenation of the myocardial tissue. 2. Reperfusion dysrhythmias indicate the ischemic heart tissue is receiving oxygen and is viable heart tissue. 3. The creatine kinase CK-MB isoenzyme elevates when there is necrotic heart tissue and does not indicate if thrombolytic therapy is successful. 4. The platelet count can decrease with administration of fibrinolytic therapy for an MI.

The nurse is administering insulin glargine to the client at 2200. The nurse asks the charge nurse to check the dosage. Which action should the charge nurse implement? 1. Ask the nurse why the insulin is being given late. 2. Check the MAR versus the dosage in the syringe. 3. Instruct the nurse to complete a medication error form. 4. Have the nurse notify the health-care provider.

Answer: 2 1. The long-acting insulin glargine (Lantus) is scheduled for bedtime. 2. The charge nurse should double-check the dosage against the MAR to make sure the client is receiving the correct dose; the long-acting insulin glargine (Lantus) does not peak and works for 24 hours. 3. There is not a medication error at this time. 4. The HCP would only need to be notified if a serious medication error has occurred.

The 68-year-old client is admitted to the emergency department with reports of slurred speech, right-sided weakness, and ataxia. The emergency department physician ordered thrombolytic therapy for the client. Which action should the nurse implement first? 1. Administer thrombolytic therapy via the protocol. 2. Send the client for a STAT CT of the head. 3. Arrange for admission to the intensive care unit (ICU). 4. Check to determine if the client is cross-sensitive to the thrombolytic.

Answer: 2 1. The nurse should prepare to administer the medication, but it is not the first intervention. 2. A CT scan must be done to rule out a hemorrhagic CVA because, if it is a hemorrhagic stroke, thrombolytic therapy will increase bleeding in the head. 3. The client receiving thrombolytic therapy will be in the ICU because the client needs constant surveillance during therapy. Heparin will be started, but this is not the first intervention. 4. The nurse should check to determine if the client is allergic to medications, but in this situation, the client must have a CT before any other action is taken. Cross sensitivity usually occurs with antibiotics, not thrombolytic therapy.

The client's vital signs are populated in the vital sign flowsheet below. Which medication would the nurse question administering? - BP: 108/72 - Temp: 99.2°F - Pulse: 59 - Respirations: 20 1. Theophylline. 2. Propranolol. 3. Ampicillin. 4. Diltiazem.

Answer: 2 1. The respiratory rate and pulse rate would not affect the administration of theophylline (Theo-Dur), a bronchodilator. 2. The apical heart rate (AP) of 59 would cause the nurse to question administering propranolol (Inderal) because beta blockers decrease the sympathetic stimulation to the heart, thereby decreasing the heart rate. 3. These vital signs would not warrant the nurse questioning administering ampicillin, an antibiotic. 4. The blood pressure is higher than 90/60; therefore, the nurse would not question administering diltiazem (Cardizem), a calcium channel blocker.

The charge nurse is observing the new graduate administering a fentanyl patch to a client diagnosed with cancer. Which action by the new graduate requires intervention by the RN charge nurse? 1. The new graduate documents the date and time on the patch. 2. The new graduate removes the patch 24 hours after it is placed on the client. 3. The new graduate rotates the application site on the client's body. 4. The new graduate checks the client's name band and date of birth.

Answer: 2 1. This is a correct intervention when applying a fentanyl (Duragesic) patch; therefore, the charge nurse would not have to intervene. 2. The fentanyl (Duragesic) patch takes about 24 hours to develop a full analgesic effect; the patch should be replaced every 72 hours. 3. The sites should be rotated to prevent irritation to the skin. 4. This is the correct way to administer all medications.

The nurse is administering an otic drop to the 45-year-old client. Which procedure should the nurse implement when administering the drops? 1. Place the drops when pulling the ear down and back. 2. Place the drops when pulling the ear up and back. 3. Place the drops in the lower conjunctival sac. 4. Place the drops in the inner canthus and apply pressure.

Answer: 2 1. This is the correct procedure for instilling eardrops for children. 2. "Otic" refers to the ear. Instilling eardrops in the adult must be done by pulling the ear up and back to straighten the eustachian tube. 3. This is the correct procedure for placing ophthalmic drops in the eye. 4. Pressure is applied to the inner canthus to prevent eye medication from entering the systemic circulation.

The nurse is administering an ophthalmic drop to the right eye. Which anatomical location would be correct when administering eyedrops? 1. Outer canthus 2. Lower conjunctival sac 3. Sclera 4. Inner canthus

Answer: 2 1. This is the outer canthus, and medications are not administered to this area. 2. The correct placement of ophthalmic drops is to administer the medication in the lower conjunctival sac. 3. This is the sclera, and the correct placement of eyedrops is in the lower conjunctival sac. 4. This is the inner canthus, where pressure can be applied gently after instilling eyedrops to help prevent the systemic absorption of ophthalmic medications.

The nurse is administering an antacid to a client diagnosed with gastroesophageal reflux disease (GERD). Which statement best describes the scientific rationale for administering this medication? 1. This medication will suppress gastric acid secretion. 2. This medication will decrease the gastric pH. 3. This medication will coat the stomach lining. 4. This medication interferes with prostaglandin production.

Answer: 2 1. This is the rationale for H-2 antagonists and proton pump inhibitors. 2. Antacids neutralize gastric acidity. 3. This is the rationale for mucosal barrier agents. 4. Prostaglandin is responsible for the production of gastric acid. Antacids do not interfere with prostaglandin production.

The client is to receive 3,000 mg of medication daily in a divided dose every 8 hours. The medication comes 500 mg per tablet. How many tablets will the nurse administer at each dose?

Answer: 2 tablets The nurse needs to determine how many doses are to be given in 1 day (24 hours) if doses are to be 8 hours apart. 24 ÷ 8 = 3 doses If 3,000 mg is to be given in three doses, then determine how much is given in each dose: 3000 ÷ 3 = 1,000 mg per dose If the medication comes in 500-mg tablets, then to give 1,000 mg, the nurse must give: 1000 ÷ 500 = 2 tablets

The client in the intensive care department is receiving 2 mcg/kg/min of dopamine. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Monitor the client's blood pressure every 2 hours. 2. Palpate the client's peripheral pulses often. 3. Use a urometer to assess hourly output. 4. Ensure the IV tubing is not exposed to the light. 5. Assess IV site for extravasation every hour.

Answer: 2, 3, 5 1. The blood pressure must be continuously monitored more often, at least every 10 to 15 minutes. 2. The peripheral pulses should be palpated frequently and the appearance of extremities should be evaluated for evidence of vasoconstriction such as cold or mottled skin. 3. The client's urine output should be monitored because low-dose dopamine, an inotropic vasopressor, is administered to maintain renal perfusion; higher doses can cause vasoconstriction of the renal arteries. 4. Dopamine is not inactivated when exposed to light. 5. Dopamine should be infused in a large vein and the administration site should be evaluated frequently for extravasation. Extravasation can cause necrosis and sloughing of surrounding tissue.

The client diagnosed with epilepsy is being discharged from the hospital with a prescription for phenytoin by mouth. Which discharge instructions should the nurse discuss with the client? Select all that apply. 1. The client should purchase a self-monitoring phenytoin machine. 2. The client should see the dentist at least every 6 months. 3. The client should never drive when taking this medication. 4. The client should not take phenytoin within 3 hours of taking an antacid. 5. The client should drink no more than one glass of wine a day.

Answer: 2, 4 1. There is no machine for home use that monitors phenytoin (Dilantin) levels. Levels are usually checked every 6 months to 1 year by venipuncture and laboratory tests. 2. Phenytoin (Dilantin) causes gingival hyperplasia, and mouth care and dental care are a priority to help prevent rotting of the teeth. 3. Some states allow seizure-free clients diagnosed with epilepsy to drive, but some states don't. The word "never" in this distracter should eliminate it as a possible correct answer. 4. Clients should be instructed to avoid taking phenytoin (Dilantin) within 2 to 3 hours of antacids. 5. Alcohol should be strictly prohibited when taking anticonvulsant medications.

The client diagnosed with type 2 diabetes is diagnosed with gout and prescribed allopurinol. Which instructions should the nurse discuss when teaching about this medication? Select all that apply. 1. The client will probably develop a red rash on the body. 2. The client should drink 2 to 3 liters of water a day. 3. The client should take this medication on an empty stomach. 4. The client will need to decrease oral diabetic medications. 5. The client should discontinue medication during an acute attack of gout.

Answer: 2, 4 1. This rash indicates a sensitivity reaction, and the allopurinol (Zyloprim) medication may need to be discontinued permanently or the dose should be decreased. 2. Increased fluid intake minimizes the risk of renal calculi formation. 3. The medication should be taken with food or milk to minimize gastric irritation. 4. Allopurinol (Zyloprim) increases the effects of oral diabetic medications; therefore, the dose should be decreased. 5. Allopurinol (Zyloprim) helps prevent acute gout attacks but does not relieve them. The client should continue the medication during an acute attack.

The client diagnosed with coronary artery disease is prescribed one low-dose acetylsalicylic acid (ASA) a day. Which instructions should the nurse provide the client concerning this medication? Select all that apply. 1. Take the medication on an empty stomach. 2. Do not crush or chew enteric-coated tablets. 3. Do not take acetaminophen while taking this drug. 4. If experiencing joint pain, notify the HCP. 5. Notify the HCP if stools become dark and tarry.

Answer: 2, 5 1. ASA (aspirin) causes GI distress and should be taken with food. 2. Enteric-coated tablets should be swallowed whole to avoid GI distress. 3. Acetaminophen (Tylenol) is recommended for pain and can be safely taken with a daily low-dose aspirin. 4. ASA (aspirin) does not cause joint pain; in fact, it may provide some relief because of its anti-inflammatory action, but when aspirin is taken daily, it is an antiplatelet medication. 5. ASA is known to cause gastric upset, which can lead to gastric bleeding, and dark, tarry stools may indicate upper GI bleeding.

The client diagnosed with postmenopausal osteoporosis is prescribed alendronate sodium. Which discharge instruction should the nurse discuss with the client? Select all that apply. 1. The medication must be taken with the breakfast meal only. 2. Remain upright for at least 30 minutes after taking medication. 3. The tablet should be chewed thoroughly before swallowing. 4. Stress the importance of having monthly hormone levels. 5. Notify the health-care provider for new or worsening heartburn.

Answer: 2, 5 1. The bisphosphonate, alendronate sodium (Fosamax), must be taken first thing in the morning before breakfast on an empty stomach; no food, juice, or coffee should be consumed for at least 30 minutes. 2. Remaining in the upright position minimizes the risk of esophagitis; the bisphosphonate, alendronate sodium (Fosamax), should be taken with 8 ounces of water. 3. The tablet should be swallowed, not chewed, and should not be allowed to dissolve until it is in the stomach. 4. There is no monthly hormone level to determine the effectiveness of the bisphosphonate, alendronate sodium (Fosamax); it is determined by a bone density test. 5. The client should notify the HCP if pain or difficulty swallowing or new or worsening heartburn occurs.

The female client diagnosed with herpes simplex 2 is prescribed valacyclovir. Which information should the nurse discuss with the client? Select all that apply. 1. Do not take this medication while pregnant; it will harm the fetus. 2. The medication does not prevent the transmission of the disease. 3. There are no side effects when taking this medication by mouth. 4. The client should get monthly liver function study tests. 5. Drink plenty of fluids while taking this medication.

Answer: 2, 5 1. Valacyclovir (Valtrex), an antiviral, is used to prevent transmission of this virus to the fetus during pregnancy and is FDA pregnancy category B. Therefore, when taken as prescribed, the client may be pregnant while taking the medication (Prescribers' Digital Reference, 2019). 2. Condoms reduce the risk of or abstinence prevents transmission of the herpes virus. 3. There are side effects to every drug; valacyclovir (Valtrex), an antiviral, causes headache, dizziness, nausea, and anorexia. 4. This medication does not directly affect the liver, and liver function tests (LFTs) are not required monthly. 5. The client should be instructed to maintain adequate hydration during the course of therapy to avoid renal side effects.

The nurse is administering morning medications. Which medication should the nurse administer first? 1. The daily digoxin to the client diagnosed with congestive heart failure. 2. The loop diuretic to the client with a serum potassium level of 3.1 mEq/L. 3. Sucralfate to the client diagnosed with peptic ulcer disease. 4. Methylprednisolone IVP to a client diagnosed with chronic lung disease.

Answer: 3 1. A daily digoxin dose is not a priority medication. 2. This potassium level is very low, and the nurse should not administer the loop diuretic. 3. The mucosal barrier, sucralfate (Carafate), must be administered on an empty stomach; therefore, it should be administered first. 4. Methylprednisolone (Solu-Medrol), an IVP medication, is not a priority over administering a medication that must be given on an empty stomach.

The nurse realizes he did not administer a medication on time to the client diagnosed with an MI. Which action should the nurse implement? 1. Administer the medication and take no further action. 2. Notify the director of nurses of the medication error. 3. Complete a medication error report form. 4. Report the error to the Peer Review Committee.

Answer: 3 1. Although many nurses will do this, the correct and ethical action is to take responsibility for the error and just be thankful the client did not have a problem. 2. There is a chain of command to report medication errors, which includes the charge nurse and the HCP, not the director of nurses. 3. The ethical and correct action is to report and document the medication error; remember always to assess the client. 4. The Peer Review Committee will not be involved in one medication error unless the client died or a life-threatening complication occurred, or if the nurse has a pattern of behavior with multiple medication errors.

The client is experiencing supraventricular tachycardia (SVT). Which antidysrhythmic medication should the nurse prepare to administer? 1. Atropine. 2. Amiodarone. 3. Adenosine. 4. Dobutamine.

Answer: 3 1. Atropine is used in clients diagnosed with asystole or symptomatic sinus bradycardia. 2. Amiodarone is a Class C medication used for ventricular dysfunction. 3. Adenosine is the drug of choice for clients diagnosed with SVT. 4. Dobutamine is used for clients diagnosed with heart failure.

The client admitted with pneumonia is taking azathioprine. Which question should the nurse ask the client regarding this medication? 1. "Do you know this medication has to be tapered off when discontinued?" 2. "Have you been exposed to viral hepatitis B or C recently?" 3. "Why are you taking this medication, and how long have you taken it?" 4. "Do you have a lot of allergies or sensitivities to different medications?"

Answer: 3 1. Azathioprine (Imuran), an immunosuppressive agent, must be taken for life because the client has to have received some type of transplant or have severe rheumatoid arthritis for it to be prescribed. 2. Exposure to hepatitis does not have anything to do with receiving this medication. 3. Azathioprine (Imuran), an immunosuppressive agent, is not a drug of choice for treating pneumonia; therefore, the nurse must find out why the client is taking it (either for a renal transplant or for severe rheumatoid arthritis). 4. Azathioprine (Imuran) does not affect the antigen-antibody reaction.

The client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) is receiving vancomycin. Peak and trough levels are ordered for the dose the nurse is administering. Which priority intervention should the nurse implement? 1. Ask if the client has had any diarrhea. 2. Monitor the aminoglycoside peak level. 3. Determine if the trough level has been drawn. 4. Check the client's culture and sensitivity report.

Answer: 3 1. Diarrhea may indicate the client may have a superinfection, but it is not the priority intervention at this time because the aminoglycoside antibiotic, vancomycin, would still be administered. 2. The peak level is not drawn until 1 hour after the medication has been infused. 3. The trough level must be drawn before administering the aminoglycoside antibiotic vancomycin; therefore, it is the priority intervention. 4. The culture and sensitivity (C&S) has already been done because it is known the client has MRSA.

The client diagnosed with end-stage renal disease is a Jehovah's Witness. The HCP orders erythropoietin subcutaneously for anemia. Which action should the nurse take? 1. Question this order because of the client's religion. 2. Encourage the client to talk to the minister. 3. Administer the medication subcutaneously as ordered. 4. Obtain the informed consent before administering.

Answer: 3 1. Erythropoietin (Epogen), a biologic response modifier, stimulates the client's own bone marrow to produce red blood cells; therefore, this is not a violation of the client's religious beliefs about blood products. 2. There is no reason for the client to have problems receiving this medication because of religious beliefs, so the client does not need to talk to the minister. 3. This medication does not violate the client's Jehovah's Witness beliefs concerning receiving blood products; therefore, the nurse should administer the erythropoietin (Epogen), a biologic response modifier, via the correct route. 4. This is not an invasive procedure or investigational medication, and thus, informed consent is not needed.

The client diagnosed with coronary artery disease is prescribed an HMG-CoA reductase inhibitor to help reduce the cholesterol level. Which assessment data should be reported to the HCP? 1. Reports of flatulence. 2. Weight loss of 2 pounds. 3. Reports of muscle pain. 4. No bowel movement for 2 days.

Answer: 3 1. Flatulence ("gas") is an expected side effect that is not life-threatening and does not need to be reported to the HCP. 2. A weight loss of 2 pounds would not need to be reported to the HCP because this medication does not affect the client's weight. 3. Muscle pain may indicate arthralgias, myositis, or rhabdomyolysis, which are complications that would cause the HCP to discontinue the medication because its continued use may lead to liver failure. 4. Not having a bowel movement may be important to the client, but clients do not have to have daily bowel movements.

The client is reporting low back pain and is prescribed carisoprodol. Which teaching intervention has priority? 1. Explain this medication causes GI distress. 2. Discuss the need to taper off this medication. 3. Warn this medication will cause drowsiness. 4. Instruct the client to limit alcohol intake.

Answer: 3 1. Muscle relaxants do not cause GI distress. 2. Muscle relaxants, with the exception of baclofen, do not need to be tapered off. 3. Initially, muscle relaxants cause drowsiness, so safety is an important issue. 4. As a safety precaution, the client should avoid drinking alcohol while taking the muscle relaxant carisoprodol (Soma).

The LPN is administering 0800 medications to clients on a medical floor. Which action by the LPN would warrant immediate intervention by the RN? 1. The LPN scores the medication to give the correct dose. 2. The LPN checks the client's armband and birth date. 3. The LPN administers sliding-scale insulin intramuscularly. 4. The LPN is 30 minutes late hanging the IV antibiotic.

Answer: 3 1. One of the rights of medication administration is the correct dose, and some medications must be divided before administering. 2. One of the rights of medication administration is the correct client, and this is making sure it is the correct client. 3. One of the rights of medication administration is the correct route. Insulin cannot be administered intramuscularly. It must be administered subcutaneously or intravenously; therefore, this action warrants immediate intervention. 4. One of the rights of medication administration is the right time, and the LPN has 30 minutes to 1 hour to administer medications depending on hospital policy; therefore, this would not require intervention by the RN.

The male client diagnosed with a chronic urinary tract infection is prescribed trimethoprim-sulfamethoxazole. Which statement indicates the client needs more teaching? 1. "I will drink six to eight glasses of water a day." 2. "I am going to have to take this medication forever." 3. "I can stop taking this medication if there is no more burning." 4. "I may get diarrhea with this medication, but I can take loperamide hydrochloride."

Answer: 3 1. The client should increase fluid intake to help flush the bacteria through the kidneys and bladder. 2. The client has a chronic UTI, which will require an antibiotic such as trimethoprim-sulfamethoxazole (Bactrim) on a daily basis to keep the bacteria count under control. 3. The key to answering this question is the word "chronic," which indicates a continuing problem; this statement would be appropriate for an acute UTI. 4. Diarrhea is a sign of superinfection, which occurs when the antibiotic trimethoprim-sulfamethoxazole (Bactrim) kills the good flora in the bowel. However, the client must keep taking the antibiotic, and loperamide hydrochloride (Imodium) is an OTC antidiarrheal.

The client diagnosed with status asthmaticus is prescribed intravenous aminophylline. Which assessment data would warrant immediate intervention? 1. The theophylline level is 12 mcg/mL. 2. The client has expiratory wheezing. 3. The client reports muscle twitching. 4. The client is refusing to eat the meal.

Answer: 3 1. The client's aminophylline drug level is within the therapeutic range of 10 to 20 mcg/mL. 2. Expiratory wheezing would be expected in the client diagnosed with status asthmaticus and, therefore, would not warrant intervention. 3. Muscle twitching indicates the client is receiving too much aminophylline, a bronchodilator, and may experience a seizure. 4. The client is having trouble breathing, and eating requires energy. Therefore, the client may not want to eat a meal or the client may not like the hospital food, which would not warrant immediate intervention.

The client diagnosed with chronic alcoholism is prescribed intravenous multivitamins. The solution turns yellow after injecting the multivitamins. Which action should the nurse implement? 1. Notify the pharmacist about the yellow discoloration of the IV. 2. Cover the IV bag and tubing with light-resistant material. 3. Administer the medication as prescribed. 4. Discard the IV bag and obtain another vial of multivitamins.

Answer: 3 1. The multivitamins in the IV solution cause the IV solution to be yellow. There is no reason to notify the HCP. 2. The IV does not need to be protected from light. 3. Multivitamins cause the IV solution to turn a yellow color and is commonly called a "banana bag." The nurse should administer the medication as prescribed. 4. The yellow color is normal for this medication.

For which client should the nurse question administering oxybutynin? 1. The client diagnosed with an overactive bladder. 2. The client diagnosed with type 2 diabetes. 3. The client diagnosed with glaucoma. 4. The client diagnosed with peripheral vascular disease.

Answer: 3 1. The muscarinic cholinergic agonist oxybutynin (Ditropan) is prescribed for clients diagnosed with an overactive bladder. 2. There is no contraindication for a client diagnosed with type 2 diabetes receiving this medication. 3. These drugs cause mydriasis. The muscarinic cholinergic agonist oxybutynin (Ditropan) increases intraocular pressure, which could lead to blindness. Glaucoma is caused by increased intraocular pressure. 4. There is no contraindication for a client diagnosed with peripheral vascular disease receiving this medication.

The nurse is administering the following 1800 medications. Which medication should the nurse question before administering? 1. The sliding-scale insulin to the client just released to have the evening meal. 2. The antibiotic to the client 1 day postoperative exploratory abdominal surgery. 3. Metformin to the client having a CT scan with contrast dye in the morning. 4. Pantoprazole to the client diagnosed with peptic ulcer disease.

Answer: 3 1. The nurse would not question administering insulin to a client about to eat. 2. The client 1 day postoperative would be receiving a prophylactic antibiotic. 3. Metformin (Glucophage), a biguanide, must be held 24 to 48 hours before receiving contrast media (dye) because Glucophage, along with the contrast dye, can damage kidney function. 4. The client diagnosed with peptic ulcer disease would be ordered a proton pump inhibitor to help decrease gastric acid production.

The client is reporting incisional pain. Which intervention should the nurse implement first? 1. Administer the pain medication STAT. 2. Determine when the last pain medication was given. 3. Assess the client's pulse and blood pressure. 4. Teach the client distraction techniques to address pain.

Answer: 3 1. The pain medication should be administered as soon as possible but not before assessing for complications that might be causing pain. 2. The nurse must not administer the medication too close to the last dose, but this is not the first intervention the nurse would implement. 3. The first step of the nursing process is to assess, and the nurse must determine if this is routine postoperative pain the client should have or if this is a complication that requires immediate intervention. Decreased blood pressure and increased pulse indicate hemorrhaging. 4. Teaching distraction techniques is an appropriate intervention, but the nurse should medicate the client.

The client diagnosed with chronic obstructive pulmonary disease is being discharged and is prescribed prednisone. Which scientific rationale supports why the nurse instructs the client to taper off the medication? 1. The pituitary gland must adjust to the decreasing dose. 2. The beta cells of the pancreas have to start secreting insulin. 3. This will allow the adrenal gland time to start functioning. 4. The thyroid gland will have to start producing cortisol.

Answer: 3 1. The pituitary gland is not directly affected by the steroid prednisone and is not why the medication must be gradually tapered. 2. Steroids do not affect the pancreas's production of insulin. 3. When the client is receiving exogenous steroids, the adrenal glands stop producing cortisol, and if the steroid prednisone is not tapered, the client can have a severe hypotensive crisis, known as adrenal gland insufficiency or Addisonian crisis. 4. The adrenal gland, not the thyroid gland, produces cortisol.

Which laboratory test should the nurse monitor for the client receiving an intravenous steroid? 1. Potassium level. 2. Sputum culture and sensitivity. 3. Glucose level. 4. Arterial blood gases.

Answer: 3 1. The potassium level is not affected by the administration of the intravenous steroid (Solu-Medrol). 2. Culture and sensitivity reports should be monitored to determine if the proper antibiotic is being administered. 3. Steroids, including the intravenous steroid (Solu-Medrol), are excreted as glucocorticoids from the adrenal gland and are responsible for insulin resistance by the cells, which may cause hyperglycemia. 4. There is no reason why the nurse would question administering a steroid based on an arterial blood gas result.

The employee health nurse is discussing hepatitis B vaccines with new employees. Which statement best describes the proper administration of the hepatitis B vaccine? 1. The vaccine must be administered once a year. 2. Two milliliters of vaccine should be given in each hip. 3. The vaccine is given in three doses over a 6-month time period. 4. The vaccine is administered intradermally into the deltoid muscle.

Answer: 3 1. The vaccine is administered in a series of three injections and is reported to be effective for life, but boosters may be given every 5 years. 2. This is the incorrect administration for the hepatitis B vaccine. 3. Hepatitis B (Engerix-B or Recombivax HB) is given in three doses—initially, then at 1 month, and then again at 6 months. An alternative administration is a two-dose hepatitis series (Heplisav-B)—two doses at least 4 weeks apart. 4. Hepatitis B vaccine is given intramuscularly in the deltoid muscle.

The nurse is preparing to administer levothyroxine to the client diagnosed with hypothyroidism. Which assessment data would indicate the client is receiving too much medication? 1. Bradypnea and weight gain. 2. Lethargy and hypotension. 3. Irritability and tachycardia. 4. Normothermia and constipation.

Answer: 3 1. These are clinical manifestations of hypothyroidism, which indicates not enough levothyroxine (Synthroid), a thyroid hormone replacement. 2. These indicate not enough medication is being administered. 3. Irritability and tachycardia are clinical manifestations of hyperthyroidism, which indicates the client is receiving too much levothyroxine (Synthroid), a thyroid hormone replacement. 4. Normothermia indicates a normal temperature, which does not indicate hypothyroidism or hyperthyroidism, and constipation is a sign of hypothyroidism.

The male client comes to the emergency department and reports he stepped on a rusty nail at home about 2 hours ago. Which question would be most important for the nurse to ask during the admission assessment? 1. "What have you used to clean the puncture site?" 2. "Did you bring the nail with you so we can culture it?" 3. "Do you remember when you had your last tetanus shot?" 4. "Are you able to put any weight on your foot?"

Answer: 3 1. This may be a question the nurse asks, but it doesn't matter because the nurse will clean the site again. 2. The nail does not matter and it will not be cultured; it is assumed the nail is contaminated. 3. The tetanus shot must be received every 10 years to prevent tetany, also known as "lockjaw." 4. Being able to walk on the foot is not a priority question. Determining the status of the tetanus shot is the priority.

The nurse is administering furosemide to the client diagnosed with essential hypertension. Which assessment data would warrant the nurse to question administering the medication? 1. The client's potassium level is 4.2 mEq/L. 2. The client's urinary output is greater than the intake. 3. The client has tented skin turgor and dry mucous membranes. 4. The client has lost 2 pounds in the last 24 hours.

Answer: 3 1. This potassium level is within normal limits; therefore, the nurse would administer the loop diuretic furosemide (Lasix). 2. This indicates the medication is effective and the nurse should not question administering the medication. 3. This indicates the client is dehydrated and the nurse should discuss this with the HCP before administering another dose of the loop diuretic furosemide (Lasix), which could increase the dehydration and could cause renal failure. 4. This indicates the medication is effective. Daily weight changes reflect fluid gain and loss.

The nurse is administering a topical ointment to the client's rash on the right leg. Which interventions should the nurse implement? Rank in order of performance. 1. Perform hand hygiene and don nonsterile gloves. 2. Cleanse the skin site and dry thoroughly. 3. Check the client's ID band and have the client state name and date of birth. 4. Explain the procedure and purpose to the client. 5. Apply the medication to the rash.

Answer: 3, 4, 1, 2, 5 3. The nurse should always check the ID band of the client and ask the client to state name and date of birth before beginning any procedure. 4. The nurse should explain the procedure and the purpose of the procedure to the client before beginning but after the identification of the client. 1. The nurse should perform hand hygiene when entering and exiting a client's room and before administering a topical ointment. Nonsterile gloves should be used for this procedure. 2. The client's leg should be cleansed before administering a new application of ointment and dried thoroughly. 5. The topical medication should be applied smoothly and evenly over the rash with a gloved hand.

The older client is admitted to the emergency department from a long-term care facility. The client has multiple ecchymotic areas on the body. The client is receiving digoxin, furosemide, warfarin, and alprazolam. Which order should the nurse request from the HCP? 1. A STAT serum potassium level. 2. An order to admit to the hospital for observation. 3. An order to administer diazepam intravenous push. 4. A STAT international normalized ratio (INR).

Answer: 4 1. A STAT potassium level would be needed for problems with digoxin, a cardiac glycoside, or furosemide (Lasix), a loop diuretic, but not for bleeding. 2. The nurse needs more information before requesting an admission to the hospital. 3. Diazepam (Valium) IVP does not help bleeding. 4. Ecchymotic areas are secondary to bleeding. The nurse should order an INR to rule out warfarin (Coumadin) toxicity.

The client is exhibiting multifocal premature ventricular contractions. Which antidysrhythmic medication should the nurse anticipate the HCP ordering for this dysrhythmia? 1. Adenosine. 2. Epinephrine. 3. Atropine. 4. Amiodarone.

Answer: 4 1. Adenosine is ordered for supraventricular tachycardia. 2. Epinephrine is administered during a code to vasoconstrict the periphery and shunt the blood to the central circulating system. 3. Atropine is used for symptomatic sinus bradycardia. 4. Amiodarone is the suggested drug of choice for ventricular irritability according to the ACLS algorithm to suppress ventricular ectopy.

The client diagnosed with end-stage renal disease is receiving aluminum hydroxide. Which assessment data indicate the medication is effective? 1. The client denies reports of indigestion. 2. The client is not experiencing burning on urination. 3. The client has had a normal, soft bowel movement. 4. The client's phosphate level has decreased.

Answer: 4 1. Aluminum hydroxide (Amphojel) is an antacid, but it is not being administered to this client for that reason. 2. The client is in end-stage renal disease (ESRD), but burning on urination is not a sign of ESRD; it is a sign of urinary tract infection. 3. A side effect of this medication is constipation, but having a normal bowel movement does not indicate the aluminum hydroxide (Amphojel) is effective. 4. Aluminum hydroxide (Amphojel) decreases the absorption of phosphates in the intestines, thereby decreasing serum phosphate levels. The normal phosphate level is 2.5 to 4.5 mg/dL.

The older male client is admitted for severe acute diverticulitis. He has been taking alprazolam for nervousness three to four times a day prn for 6 years. Which intervention should the nurse implement first? 1. Prepare to administer an intravenous antianxiety medication. 2. Notify the HCP to obtain an order for the client's alprazolam prn. 3. Explain alprazolam causes addiction and he should quit taking it. 4. Assess for clinical manifestations of medication withdrawal.

Answer: 4 1. Because the client is NPO as a result of the admitting diagnosis, the client needs alternative antianxiety medication to prevent clinical withdrawal manifestations, but this is not the first intervention. 2. The client will be NPO as a result of the diverticulitis, and alprazolam (Xanax), a benzodiazepine, is administered orally; therefore, another route of medication administration is needed, but this is not the first intervention. 3. This is correct information, but it is not the priority intervention. 4. Alprazolam (Xanax) has a greater dependence problem than all the other benzodiazepines; therefore, the nurse must assess for clinical withdrawal manifestations first. Then the nurse can implement the other interventions. The client needs to be withdrawn slowly from the benzodiazepines, but an assessment is a priority.

The client diagnosed with asthma is prescribed cromolyn. Which statement by the client indicates the need for further teaching? 1. "I will take two puffs of my inhaler before I exercise." 2. "I will rinse my mouth with water after taking the medication." 3. "After inhaling the medication, I will hold my breath for 10 seconds." 4. "When I start to wheeze, I will use my inhaler immediately."

Answer: 4 1. Cromolyn, a mast cell inhibitor, is used prophylactically to prevent exercise-induced asthma attacks. It is administered in routine daily doses to prevent asthma attacks. 2. Rinsing the mouth will help prevent the growth of bacteria secondary to medication left in the mouth. 3. Holding the breath for 10 seconds keeps the medication in the lungs. 4. The mast cell inhibitor, cromolyn, is used to stabilize the mast cells in the lungs. During an asthma attack, the mast cells are already unstable; therefore, this medication will not be effective in treating the acute asthma attack. This statement would require the nurse to reteach about the medication.

The UAP reported an intake of 1,000 mL and urinary output of 1,500 mL for a client receiving a thiazide diuretic. Which nursing task could the RN delegate to the nursing assistant? 1. Instruct the UAP to restrict the client's fluid intake. 2. Request the UAP to insert a Foley catheter with a urometer. 3. Tell the UAP urinary outputs are no longer needed. 4. Ask the UAP to document fluids on the I & O record at the bedside.

Answer: 4 1. Output greater than intake indicates the medication is effective, and there is no need to restrict fluid intake. 2. There is no reason to insert a Foley catheter in the client urinating without difficulties. 3. As long as the client is receiving diuretics, the client should be on intake and output monitoring. 4. The UAP can document the client's fluid intake and output numbers on the bedside record; this is one of the UAP's duties.

The client in the intensive care department has a nasogastric tube for continuous feedings. The nurse is preparing to administer nifedipine extended release (XL) via the NG tube. Which procedure should the nurse follow? 1. Crush the medication and dissolve it in water. 2. Administer and flush the NG tube with cranberry juice. 3. Give the medication orally with pudding. 4. Do not administer the medication and notify the HCP.

Answer: 4 1. The XL means the nifedipine (Procardia XL) is extended release and cannot be crushed. 2. Whole capsules or tablets cannot be administered through a feeding tube. 3. The client has a feeding tube and is not able to swallow; therefore, the nurse should not administer the nifedipine (Procardia XL) orally. 4. Tablets that are enteric coated or extended release cannot be crushed and administered via the NG tube. This would allow 24 hours' worth of medication into the client's system at one time. The nurse should ask the HCP to change the nifedipine (Procardia XL) medication to a form that is not enteric coated and not extended release. Then it can be crushed and administered through the feeding tube.

The nurse is preparing to administer the morning dose of digoxin to a client diagnosed with congestive heart failure. Which data would indicate the medication is effective? 1. The apical heart rate is 72 beats per minute. 2. The client denies having any anorexia or nausea. 3. The client's blood pressure is 120/80 mm Hg. 4. The client's lungs sounds are clear bilaterally.

Answer: 4 1. The apical heart rate is assessed before administering the digoxin, a cardiac glycoside, but it does not indicate the medication is effective. 2. Anorexia and nausea are clinical manifestations of digoxin toxicity and do not indicate if the medication is effective. 3. Digoxin has no effect on the client's blood pressure. 4. Digoxin, a cardiac glycoside, is administered for heart failure and dysrhythmias. Clear lung sounds indicate the heart failure is being controlled by the medication.

The client is in end-stage renal disease and is receiving sodium polystyrene sulfonate via an enema. Which data indicate the medication is effective? 1. The client has 30 mL/hr of urine output. 2. The serum phosphorus level has decreased. 3. The client is in normal sinus rhythm. 4. The client's serum potassium level is 5 mEq/L.

Answer: 4 1. The client diagnosed with end-stage renal disease does not normally urinate, and urine output does not determine if this medication is effective. 2. Sodium polystyrene sulfonate (Kayexalate) does not affect phosphorus levels. 3. The client being in normal sinus rhythm is good, but it does not determine if the medication is effective. 4. Sodium polystyrene sulfonate (Kayexalate) is a cation and exchanges sodium ions for potassium ions in the intestines, thereby lowering the serum potassium level. Therefore, a serum potassium level within normal limits would indicate the medication is effective. Normal potassium levels are 3.5 to 5.3 mEq/L.

The client diagnosed with adult-onset asthma is being discharged. Which medication would the nurse expect the HCP to prescribe? 1. A nonsteroidal anti-inflammatory medication. 2. An antihistamine medication. 3. An angiotensin-converting enzyme inhibitor. 4. A proton pump inhibitor.

Answer: 4 1. The client may be given a steroid, such as prednisone, but not an NSAID. 2. An antihistamine is prescribed to decrease clinical manifestations of a cold or the flu, but it is not prescribed for asthma. 3. An ACE inhibitor prevents deterioration of heart muscle and kidneys, but it is not a drug of choice for the respiratory system. 4. Adult-onset asthma can be caused or aggravated by gastroesophageal reflux disease; therefore, a proton pump inhibitor would be prescribed to decrease acid reflux into the esophagus and subsequent aspiration.

The client is diagnosed with essential hypertension and is receiving a calcium channel blocker. Which assessment data would warrant the nurse holding the client's medication? 1. The client's oral temperature is 102°F. 2. The client reports a dry, nonproductive cough. 3. The client's blood pressure reading is 106/76. 4. The client reports being dizzy when getting out of bed.

Answer: 4 1. The client's temperature would not affect the administration of this medication. 2. ACE inhibitors sometimes cause the client to develop a cough, which requires discontinuing the medication, but this is a calcium channel blocker. 3. This blood pressure reading indicates the client's medication is effective. 4. This indicates orthostatic hypotension, and the nurse should assess the client's BP before administering the medication.

The client diagnosed with diabetes insipidus is receiving vasopressin intranasally. Which assessment data indicate the medication is effective? 1. The client reports being able to breathe through the nose. 2. The client reports being thirsty all the time. 3. The client has a blood glucose of 99 mg/dL. 4. The client is urinating every 3 to 4 hours.

Answer: 4 1. The medication is administered through the nose, but it has no effect on the client's ability to breathe. 2. Being thirsty all the time would indicate the vasopressin is not effective. 3. Neither the medication nor the disease process has anything to do with the glucose level. A disease that affects the glucose level is diabetes mellitus, not diabetes insipidus. 4. Diabetes insipidus is characterized by the client not being able to concentrate urine and excreting large amounts of dilute urine. If the client is able to delay voiding for 3 to 4 hours, it indicates the vasopressin medication is effective.

The nurse administered an IV broad-spectrum antibiotic scheduled every 6 hours to the client diagnosed with a systemic infection at 0800. At 1000, the culture and sensitivity prompted the HCP to change the IV antibiotic. When transcribing the new antibiotic order, when would the initial dose be administered? 1. Schedule the dose for 1400. 2. Schedule the dose for the next day. 3. Check with the HCP to determine when to start. 4. Administer the dose within 1 hour of the order.

Answer: 4 1. The new antibiotic must be started as soon as the medication arrives from the pharmacy. 2. Waiting until the next day could cause serious harm, with the client possibly going into septic shock. 3. The HCP does not determine when the medications are administered; this is a nursing intervention. 4. A new IV antibiotic must be initiated as soon as possible, at least within 1 hour. A broad-spectrum antibiotic is ordered until C&S results are determined. Then, an antibiotic that will specifically target the infectious organism must be started immediately.

The client asks the clinic nurse about taking 2,000 mg of ascorbic acid (vitamin C) a day to prevent getting a cold. On which scientific rationale should the nurse base the response? 1. Vitamin C in this dosage will help cure a common cold. 2. This vitamin must be taken with echinacea to be effective. 3. This dose of vitamin C is not high enough to help prevent colds. 4. Megadoses of vitamin C may cause crystals to form in the urine.

Answer: 4 1. The normal recommended daily dose of vitamin C is 60 to 90 mg for healthy adults, but nothing cures the virus that causes the common cold. 2. Echinacea is an herbal preparation thought to limit the severity of a cold and is sold in OTC preparations, but it does not have to be taken with vitamin C. 3. This dose is already too high, and water-soluble vitamins in excess of the body's needs are excreted in the urine. 4. Megadoses can lead to crystals in the urine, and crystals can lead to the formation of renal calculi (stones) in the kidneys.

The client had a kidney transplant and told the nurse about taking St. John's wort for depression. Which action should the nurse take first? 1. Praise the client for taking the initiative to treat the depression. 2. Remain nonjudgmental about the client's alternative treatments. 3. Refer the client to a psychologist for counseling for depression. 4. Instruct the client to quit taking the medication immediately.

Answer: 4 1. The nurse should investigate any herbs, such as St. John's wort, a client is taking, especially if the client has a condition that requires long-term medication, such as antirejection medication. 2. The nurse should remain nonjudgmental but must intervene if the alternative treatment, St. John's wort, poses a risk to the client. 3. The client may need to be referred for psychological counseling, but it is not the first action the nurse should take. 4. St. John's wort, an herb, decreases the effects of many medications, including oral contraceptives, antiretrovirals, and transplant immunosuppressant drugs. Rejection of the client's kidney could occur if the client continues to use St. John's wort.

The client in the emergency department requires sutures for a laceration on the left leg. Which information is most pertinent before suturing the wound? 1. The client tells the nurse she has never had sutures. 2. The spouse refuses to leave the room during suturing. 3. The client shares she is scared of needles. 4. The client reports hives after having dental surgery.

Answer: 4 1. This information really doesn't have a bearing on the current situation. 2. The spouse can stay in the room if able to stay calm and not upset the client. 3. The nurse should address the client's fear, but it is not the most pertinent information. 4. A local anesthetic will be administered to numb the area before suturing. The same classification of drugs is used to numb the mouth before dental procedures, and this client may be allergic to the numbing medication.

The client on bedrest is receiving enoxaparin. Which anatomical site is recommended for administering this medication? 1. The abdominal wall 1 inch away from the umbilicus. 2. The vastus lateralis with a 23-gauge needle. 3. In the deltoid area, subcutaneously. 4. In the anterolateral abdomen.

Answer: 4 1. This is the correct area to administer subcutaneous heparin, but not enoxaparin (Lovenox), a low molecular weight heparin. 2. This is in the client's anterior thigh, which may be used for insulin administration but not for Lovenox, and a 25-gauge 1/2-inch needle is used to administer Lovenox. 3. This is the upper arm area, which is used for subcutaneous insulin, but not enoxaparin (Lovenox), a low molecular weight heparin. 4. Enoxaparin (Lovenox), a low molecular weight heparin, is administered in the "love handles," which is in the anterolateral or posterolateral abdomen to enhance absorption. Sites should be rotated frequently.

The HCP has ordered an intramuscular antibiotic. After reconstituting the medication, the clinic nurse must administer 5.5 mL of the medication. Which action should the nurse implement first when administering this medication? 1. Inform the HCP the amount of medication is too large. 2. Administer the medication in the dorsogluteal muscle. 3. Discard the medication in the sharps container. 4. Divide the medication and give 2.75 mL in each hip.

Answer: 4 1. This medication amount is too much and must be divided into two injections to be given safely, but the nurse can do this independently and does not need to notify the HCP. 2. The nurse should not administer 5.5 mL in one injection. No more than 3 to 5 mL should be administered in an intramuscular injection (Treas et al., 2018). 3. There is no reason for the nurse to discard this medication. Divide the medication and give two injections. 4. The nurse should never administer more than 3 to 5 mL in an intramuscular injection because a larger amount could cause damage to the muscle. The nurse should divide the dose and administer two injections.

The client received naloxone following a procedure. Which action by the nurse has the highest priority? 1. Document the occurrence in the nurse's notes. 2. Prepare to administer narcotic medication IV. 3. Administer oxygen via nasal cannula. 4. Assess the client every 15 to 30 minutes.

Answer: 4 1. This should be documented in the client's nurse's notes because this is a prn medication, but it is not the priority action. 2. The nurse would not administer another narcotic, which is what caused the need for naloxone (Narcan), a narcotic antagonist, in the first place. 3. Oxygen will not help reverse respiratory depression secondary to a narcotic overdose. 4. Naloxone (Narcan), a narcotic antagonist, is administered when the client has received too much of a narcotic. Narcan has a short half-life of about 30 minutes, and the client will be at risk for respiratory depression for several hours; therefore, the nurse should assess the client frequently.

The nurse administers 18 units of insulin isophane at 1630. Which priority intervention should the nurse implement? 1. Monitor the client's hemoglobin A1c. 2. Make sure the client eats the evening meal. 3. Check the a.c. blood glucometer reading. 4. Ensure the client eats a snack.

Answer: 4 1. This test monitors the client's average blood glucose level over the previous 3 months. 2. The evening meal would prevent hypoglycemia for regular insulin administered at 1630. 3. The before-meal (a.c.) blood glucose level done at 1630 would not be affected by the insulin administered after that time. 4. Insulin isophane (Humulin N), an intermediate-acting insulin, peaks 6 to 8 hours after being administered; therefore, the nighttime snack (h.s.) will prevent late-night hypoglycemia.

The nurse has received the morning report and has the following medications due or being requested. In which order should the nurse administer the medications? Rank in order of priority. 1. Administer furosemide IVP daily to a client diagnosed with heart failure and is dyspneic on exertion. 2. Administer morphine IVP prn to a client diagnosed with lower back pain reporting pain at a "10" on a 1-to-10 scale. 3. Administer neostigmine PO to a client diagnosed with myasthenia gravis. 4. Administer lidocaine IVP prn to a client in normal sinus rhythm with multifocal premature ventricular contractions. 5. Administer vancomycin to a client diagnosed with a Staphylococcus infection and a trough level of 14 mg/dL.

Answer: 4, 3, 2, 1, 5 4. Although the lidocaine, an antidysrhythmic, is a prn order, this client is exhibiting a life-threatening dysrhythmia, multifocal premature ventricular contractions. 3. The client diagnosed with myasthenia gravis must have this medication as close to the specific time as possible. Neostigmine (Prostigmin), a cholinesterase inhibitor, allows skeletal muscle to function; if this medication is delayed, the client may experience respiratory distress. 2. Pain is a priority, and morphine, a narcotic analgesic, should be administered after administering medications to clients diagnosed with life-threatening situations. 1. This client is symptomatic, and the furosemide (Lasix), a loop diuretic, should relieve some of the clinical manifestations of dyspnea. 5. Intravenous antibiotics are a priority, but this client has received several doses of vancomycin, an aminoglycoside antibiotic, or there would not be a trough level, so this client's medication could wait until the other medications have been administered.

The client is receiving a continuous heparin drip, 20,000 units/500 mL D5W, at 23 mL/min. How many units of heparin is the client receiving an hour? units/hr

Answer: 920 units/ hr 20000 units ÷ 500 mL = 40 units/mL40 units/mL × 23 mL/hr = 920 units/hr