Medication and IV Administration
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What size needle would you use for an IM on an infant?
-A 1" (2.5-cm), 22G to 25G needle is adequate to penetrate the thigh muscle (vastus lateralis) of most infants.
What size needle would you use for an IM on a neonate?
-A ⅝" (1.6-cm), 22G to 25G needle is adequate to penetrate the thigh muscle (vastus lateralis)
Where do you locate the ventrogluteal location for an IM injection?
-Have patient to sit, stand, or lie in the lateral (side laying) or supine position. -To identify the injection site, locate the greater trochanter of the patient's femur with the heel of your hand and then spread your index and middle fingers from the anterior superior iliac spine to as far along the iliac crest as you can reach. The injection site should be located in the area between the two fingers, at a 90-degree angle to the muscle. To prevent needlestick injury, remove your fingers before performing the injection. The maximum injection volume for this area is 5 mL.
Where do you locate the vastus lateralis location for an IM injection?
-Instruct the patient to sit or lie in the supine position. -If necessary, flex the patient's knee slightly and rotate the foot externally to relax the muscle. -Use the vastus lateralis, which is the lateral muscle of the quadriceps group that extends from one handbreadth below the patient's greater trochanter to one handbreadth above the knee. -Insert the needle into the outer middle third of the muscle, parallel to the surface on which the patient is lying. -The maximum injection volume for this area is 5 mL
What is the Z-track method?
-Preferred for administering IM's -it prevents leakage (or tracking) of medication into the subcutaneous tissue, which may cause patient discomfort and stain some tissue permanently. -Lateral displacement of the skin during Z-track injection helps seal the medication in the muscle. -Use about a 1 1/2 inch needle
Where do you locate the deltoid location for an IM injection?
-Pt can sit or stand -Find the lower edge of the patient's acromion process and the point on the lateral arm in line with the axilla. -Insert the needle 1" to 2" (2.5 to 5 cm) below the acromion process, usually two or three fingerbreadths, at a 90-degree angle or angled toward the process slightly. -The maximum injection volume for this area is 2 mL
Preferred IM injection site for a Toddlers (age 12 months up to 3 years) - name needle size & length
-The vastus lateralis muscle of the anterolateral aspect of the thigh (shown above) is the preferred site for IM injection in a toddler. The needle should be 22G to 25G and at least 1". -You can use the deltoid muscle (shown below) if the muscle mass is adequate. Use of a ⅝" (1.6-cm) needle is adequate if you stretch the skin between your thumb and forefinger and insert the needle at a 90-degree angle to the skin
Step by step instructions for an IM injection:
-position the patient -Clean IM injection site using an alcohol pad , moving the pad outward in a circular motion to a circumference of about 2" (5 cm) from the injection site. Then allow the patient's skin to dry. -Remove the needle sheath. Displace the patient's skin laterally using your nondominant hand (z-track) by pulling or pushing it ¾" to 1¼ " (2 to 3 cm) away from the IM injection site. -Position the syringe at a 90-degree angle to the surface of the patient's skin, with the needle about 2" (5 cm) from the skin. -Tell the patient to expect to feel a prick as you insert the needle. -Insert the needle quickly and smoothly through the patient's skin and subcutaneous tissue and deep into the muscle at a 90-degree angle. -Inject the medication according to the manufacturer's prescribing information. -Wait 10 seconds to ensure dispersion of the prescribed medication, and then withdraw the needle slowly at a 90-degree angle. -Remove your thumb and index finger from the surface of the patient's skin, allowing the displaced skin and subcutaneous tissue to return to their normal positions to seal the needle track, trapping the prescribed medication in the muscle. -Don't massage the IM injection site or allow the patient to wear a tight-fitting garment over the site because doing so may force the medication into subcutaneous tissue. -Activate the needle safety device, if available, and discard the needle and syringe in a puncture-resistant sharps container. -Don't recap the needle to avoid needlestick injuries.
Preferred fIM injection site for an infant (younger than 12 months)
-the vastus lateralis muscle of the anterolateral aspect of the thigh -This is the recommended site for injection because it provides a large muscle mass. -A 1" (2.5-cm), 22G to 25G needle is adequate to penetrate the thigh muscle of most infants. -For neonates and preterm infants, a ⅝" (1.6-cm) needle is usually adequate
Typical needle length for subcutaneous
1/2 to 5/8 inches (1.3 to 1.6 cm) in length
How long do you leave the needle in the skin after injection to ensure ispersion of the prescribed medication?
10 seconds
What angle do you inject an ID injection?
15 degrees
What is the maximum injection volume for the deltoid?
2 mL
Subcutaneous injections are administered at what angle?
45-90 degrees
What angle do you inject an IM injection?
90 degrees
A client with hospital-acquired pneumonia (HAP) is told that the intravenous (I.V.) antibiotics will be discontinued and will now taken orally. What information needs to be included when the nurse explains the change to the client and family member? Select all that apply. A. A description of the client's current clinical progress B. the rationale for continuing to take the medication orally C. an explanation of antibiotic-resistant microorganisms D. the acknowledgment of a healthy gastrointestinal tract E. a clarification that discharge is postponed if on I.V. medication
A. A description of the client's current clinical progress B. the rationale for continuing to take the medication orally D. the acknowledgment of a healthy gastrointestinal tract Explanation: The explanation for changing a client from I.V. antibiotic medication to oral antibiotic medication needs to include information about the client's current clinical progress, the explanation for continuing to take oral antibiotics after the I.V. antibiotics are discontinued, and that by having a healthy gastrointestinal tract the medication will be absorbed and metabolized by the body. These factors allow for treatment progression and discharge from the hospital. The information related to antibiotic-resistant microorganisms does not directly relate to the client's concern. It is possible to be discharged even when I.V. medications are required by the client.
What therapeutic class is enoxaparin?
Anticoagulant
A nurse is providing instruction to a client undergoing treatment for anxiety and insomnia. The practitioner has prescribed lorazepam 1 mg PO t.i.d.. The nurse determines that teaching has been effective when the client states A. "I'll avoid coffee." B. "I can drink red wine." C. "I'll avoid sunlight." D. "I must eat enough salt."
Correct response: "I'll avoid coffee." Explanation: Lorazepam is a benzodiazepine used to treat various forms of anxiety and insomnia. Caffeine is contraindicated because it is a stimulant and increases anxiety. A client taking lorazepam should avoid alcoholic beverages. Clients taking certain antipsychotic medications should avoid sunlight. Salt intake has no effect on lorazepam.
The nurse is teaching a client about glaucoma treatments. What statement by a client demonstrates an understanding of the need for medication adherence? A. "I will experience diplopia if I don't take my medication as ordered." B." If I don't take my medication as ordered, I will experience permanent vision loss." C. "It is important to take my medication as ordered to prevent anticholinergic effects." D. "I will experience pupillary constriction if I don't take my medication as ordered."
Correct response: " If I don't take my medication as ordered, I will experience permanent vision loss." Explanation: Without treatment, glaucoma may progress to irreversible blindness. Treatment won't restore visual damage but will halt disease progression. Blurred or foggy vision, not diplopia, is typical in glaucoma. Miotics, which constrict the pupil, are used to treat glaucoma and to permit outflow of the aqueous humor. Clients with glaucoma should avoid medications with anticholinergic effects, but taking glaucoma medications cannot prevent these effects.
Which instruction should a nurse give a client with prostatitis who is receiving co-trimoxazole double strength? -"Don't expect improvement of symptoms for 7 to 10 days." -"Drink 6 to 8 glasses of fluid daily while taking this medication." -"If your mouth or throat becomes sore, take the medication with milk or an antacid." -"To protect against drug-induced photosensitivity, use a sunscreen of at least SPF-15 with PABA."
Correct response: "Drink 6 to 8 glasses of fluid daily while taking this medication." Explanation: The client must drink 6 to 8 glasses of fluid daily to prevent renal problems, such as crystalluria and stone formation. If the drug is effective, symptoms should improve within a few days. Sore throat and sore mouth are adverse effects; the client should report them to a physician right away. The drug causes photosensitivity, but the client should use a PABA-free sunscreen; PABA can interfere with the drug's action.
A client is receiving aspirin. Which statement made by the client needs follow-up? "I need to report if I have black stool." "I'll take the medication after a meal." "I can take Ginkgo biloba with aspirin." "I need to report loss of hearing in my ears."
Correct response: "I can take Ginkgo biloba with aspirin." Explanation: Aspirin, also known as acetylsalicylic acid, is used for mild to moderate pain, fever, inflammation, and atrial fibrillation stroke prevention. Aspirin may increase the bleeding when taken with herbal supplement Ginkgo biloba. The medication can cause gastrointestinal bleeding and ototoxicity. Nausea, vomiting, diaphoresis, and tinnitus are the earliest signs and symptoms of salicylate toxicity. Other early symptoms and signs are vertigo, hyperventilation, tachycardia, and hyperactivity. It should be taken with food especially if it causes stomach upset.
The nurse reviews information about how to take the prescribed tetracycline. Which statement by the client allows the nurse to determine that the client understands the information? A. "I can take tetracycline with or without meals." B. "I can take tetracycline with milk and milk products." C. "I can take tetracycline on an empty stomach with small amounts of water." D. "I can take tetracycline 1 hour before or 2 hours after meals with plenty of water."
Correct response: "I can take tetracycline 1 hour before or 2 hours after meals with plenty of water." Explanation: Tetracycline must be taken on an empty stomach to increase absorption, and with ample water to avoid esophageal irritation. Milk products impede absorption.
A client is taking fluphenazine. The nurse understands that teaching and discharge instructions are understood when the client states: "I need to stay out of the sun." "I need to double my fluids." "I can't eat cheese or eggs." "I need to plan frequent naps."
Correct response: "I need to stay out of the sun." Explanation: Fluphenazine is an antipsychotic drug that can cause photosensitivity and sunburn. Clients taking this drug don't need to increase fluid intake, avoid cheese or eggs, or plan rest periods.
A nurse is teaching a client with glaucoma the proper technique for instilling eye drops. The nurse determines that teaching is effective when the client states: A. "I should instill the drop directly onto the cornea." B. "I should instill the drop in the outer canthus." C. "I should instill the drop near the opening of the lacrimal duct." D. I should instill the drop in the lower conjunctival sac."
Correct response: "I should instill the drop in the lower conjunctival sac." Explanation: Eye drops should be placed in the lower conjunctival sac starting at the inner, not outer, canthus. Placing eye drops on the cornea causes discomfort and should be avoided. Eye drops shouldn't be placed by the opening of the lacrimal ducts to avoid systemic absorption.
The nurse is caring for a client being treated for pedophilia. The client discloses that the dose of medroxyprogesterone is not helping to reduce sexual impulses. What is the nurse's most appropriate response? "That is an off-label use for that medication." "I will review your lab results and medication dosage." "How are you tolerating that hormone therapy?" "Have you registered yet as a sex offender?
Correct response: "I will review your lab results and medication dosage." Explanation: The nurse should reinforce that testosterone suppression can take from 3 to 10 months to realize symptom relief. It is important to understand serum levels as well as dosage before contacting the prescriber about a change in dosage. It is also helpful to learn how the client is tolerating the hormone, but this is not of primary importance. Hormone replacement therapy, as a treatment for this disorder, is not done universally. It is inappropriate to overreact about the disorder, or the provider's chosen treatment for this client.
An adolescent with cystic fibrosis has been placed on ciprofloxacin for a lung infection. Which statement from the client indicates the need for more teaching? -"I won't take this drug with any dairy products." -"I'll need to have drug levels drawn while I'm on this medication." -"I should immediately report any muscle or joint pain." -"If I miss a dose, I should take it as soon as I remember."
Correct response: "I'll need to have drug levels drawn while I'm on this medication." Explanation: Therapeutic serum drug monitoring is not routinely done with ciprofloxacin. Therefore, if the client believes that blood levels will need to be taken, further teaching is required. This medicine should not be taken with dairy products or other significant sources of calcium such as collard greens, calcium supplements, calcium carbonate antacids, or calcium-fortified juice. Clients may usually take a missed dose as soon as they remember; if it is very close to the time of the next dose, the missed dose should be omitted to avoid taking a double dose. Drug Because ciprofloxacin is associated with increased risk of tendinitis and tendon rupture, the client should report muscle or joint pain immediately.
Which statement by a student nurse demonstrates that further instruction about cytotoxic drugs is needed? A. "Cytotoxic parenteral infusion containers should be marked with special hazard labels." B. "Infusion set administration connections should be tight." C. "Nurses who are pregnant must wear gloves during administration of cytotoxic drugs." D. "Linen contaminated with blood or body fluids of a client receiving cytotoxic drugs should be placed in a leak-proof container and marked with a chemotherapy hazard label."
Correct response: "Nurses who are pregnant must wear gloves during administration of cytotoxic drugs." Explanation: Pregnant nurses should not administer cytotoxic drugs because long-term exposure to cytotoxic drugs may be associated with teratogenic effects. Nonpregnant nurses should wear double gloves and long sleeve disposable gowns while administering cytotoxic drugs. To prevent exposure and leakage, the nurse should mark all parenteral infusion containers with hazard labels and check infusion container connections before drug administration. Linens that have become contaminated by blood or body fluid of a client receiving chemotherapy should be handled with caution, placed in a leak-proof, closed system and labeled "chemotherapy contaminated linens."
2/10180019-year-old client with mild concussion after slipping in school parking lot three hours prior. No loss of consciousness. No appreciable neurological deficits. CT scan normal. Client was preparing for discharge. Now reports a 5/10 headache. Acetaminophen PO prescribed.When offered acetaminophen, the client's parents tell the nurse that they would like their child to have something stronger. What is the nurse's best response? A. "Acetaminophen is strong enough for your child's mild concussion." B. "We avoid giving aspirin to children and young adults because of the danger of Reye syndrome." C. "Opioids are avoided following a head injury because they may hide a deteriorating condition." D. "Stronger medications may lead to vomiting, which increases the intracranial pressure."
Correct response: "Opioids are avoided following a head injury because they may hide a deteriorating condition." Explanation: Opioids may mask changes in the level of consciousness (LOC) that indicate increased intracranial pressure (ICP) and should therefore not be given as a first-line drug in this situation. Stating that acetaminophen is strong enough ignores the parents' concern and is not appropriate. Aspirin is contraindicated in conditions that include bleeding, as well as for children or young adults with viral illnesses due to the danger of Reye syndrome; the Reye syndrome caution does not apply here. Stronger medications could lead to vomiting but would definitely sedate the client, thereby masking changes in the client's LOC, the priority concern here.
A client with chronic pancreatitis is discharged with a prescription for pancrelipase. Which instruction must the nurse include when providing discharge instructions regarding this medication? "Store this medication in the refrigerator." "Take this medication before going to bed." "Dissolve the medication in a full glass of water." "Swallow this medication whole. Do not chew it."
Correct response: "Swallow this medication whole. Do not chew it." Explanation: Digestion begins in the mouth. Pancrelipase needs to be swallowed whole in order to reach the stomach before digestion begins and cannot be crushed, chewed, or held in the mouth. In order for the medication to be effective, it must be taken before meals or snacks. The medication needs to be stored in a dry place but does not require refrigeration.
The client with breast cancer is prescribed tamoxifen 20 mg daily. The client states she does not like taking medicine and asks the nurse if the tamoxifen is really worth taking. What should the nurse tell the client? "This drug is part of your chemotherapy program." "This drug has been found to decrease metastatic breast cancer." "This drug will act as an estrogen in your breast tissue." "This drug will prevent hot flashes since you cannot take hormone replacement."
Correct response: "This drug has been found to decrease metastatic breast cancer." Explanation: Tamoxifen is an antiestrogen drug that has been found to be effective against metastatic breast cancer and to improve the survival rate. The drug causes hot flashes as an adverse effect.
Which statement by a client who has been taking buspirone as prescribed for 2 days indicates the need for further teaching? "This medication will help my tight, aching muscles." "I may not feel better for 7 to 10 days." "The drug does not cause physical dependence." "I can take the medication with food."
Correct response: "This medication will help my tight, aching muscles." Explanation: Buspirone, a nonbenzodiazepine anxiolytic (antianxiety), is particularly effective in treating the cognitive symptoms of anxiety, such as worry, apprehension, difficulty with concentration, and irritability. Buspirone is not effective for the somatic symptoms of anxiety (muscle tension). Therapeutic effects may be experienced in 7 to 10 days, with full effects occurring in 3 to 4 weeks. This drug is not known to cause physical or psychological dependence. It can be taken with food or small meals to reduce gastrointestinal upset.
A client who is using a patient-controlled analgesia (PCA) pump after bowel surgery states, "I'm afraid that I'll become addicted if I use too much morphine." Which would be the best response by the nurse? -"Morphine is not addicting in these circumstances. Why are you worried about it?" -"You need to take the morphine to help you rest and recuperate from the surgery; you can deal with the addiction later." -"When morphine is used to alleviate severe pain for 2 to 3 days, there is little likelihood of becoming addicted." -"Have you had problems with drug addiction before?"
Correct response: "When morphine is used to alleviate severe pain for 2 to 3 days, there is little likelihood of becoming addicted." Explanation: Morphine is a narcotic. Clients need to understand that when pain is present and morphine is used therapeutically, there is less likelihood of addiction. If morphine is taken in the absence of pain, addiction can result. Telling the client that morphine is not addicting in this circumstance is incorrect because, although it acknowledges the addictive nature of morphine, it does not inform the client of its utility in pain management. Asking about prior drug addiction is not appropriate at this time; the client would be assessed for risk of addiction or abuse before extended-release or long-acting forms of morphine were prescribed, but these forms are generally not used for postoperative pain.
The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should perform the actions in order of what priority from first to last? All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. -Position rolled towel under client's back, parallel to the spine. -Change dressing per institutional policy. -Obtain a culture from the drainage at the insertion site. -Notify the health care provider.
Correct response: -Notify the health care provider. -Position rolled towel under client's back, parallel to the spine. -Obtain a culture from the drainage at the insertion site. -Change dressing per institutional policy. Explanation: A potential complication of receiving TPN is leakage or catheter puncture; the nurse should first notify the health care provider and prepare for changing of the catheter. Next, if pneumothorax is suspected, position a rolled towel under the client's back. If there is drainage at the insertion site, the nurse should then obtain a culture from the drainage and lastly, change the dressing using sterile technique.
A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of [800 mg/dl (44.4 mmol/L)]. Which solution is the most appropriate at the beginning of therapy? -100 units of regular insulin in normal saline solution -100 units of neutral protamine Hagedorn (NPH) insulin in normal saline solution -100 units of regular insulin in dextrose 5% in water -100 units of NPH insulin in dextrose 5% in water
Correct response: 100 units of regular insulin in normal saline solution Explanation: Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia.
The supervisor is performing a chart review. The nurse can be held legally liable for which documentation? A. 0800 administered 2 mg hydromorphone IVP per PRN orders of 1 to 2 mg every 4 hours -BSmith, RN B. 0900 Withheld digoxin dose. Client's apical pulse is 56 beats/min -BSmith, RN C. 0900 Withheld mononitrate dose. Client's blood pressure is 80/40 mmHg -BSmith, RN D. 1200 Administered cephalosporin. The client has an allergy to penicillin -BSmith, RN
Correct response: 1200 Administered cephalosporin. The client has an allergy to penicillin -BSmith, RN Explanation: There is a cross-sensitivity between cephalosporin and penicillin, and the drug should not have been given. When a dosage range is ordered, any dose in that range is acceptable. Digoxin is a cardiac glycoside that acts to improve the efficiency of the heart and may slow the heart rate and the drug should not ordinarily be given if the apical pulse is less the 60. Mononitrate is a nitrate that can cause vasodilation and should not be given when hypotension is present.
The health care provider (HCP) changes a client's current dose of IM meperidine hydrochloride to an oral dosage. The current IM dosage is 75 mg every 4 hours as needed. What dosage of oral meperidine will be required to provide an equivalent analgesic dose? 25 to 50 mg every 4 hours 75 to 100 mg every 4 hours 125 to 140 mg every 4 hours 150 to 300 mg every 4 hours
Correct response: 150 to 300 mg every 4 hours Explanation: The equianalgesic dose of oral meperidine hydrochloride is up to four times the IM dose. Meperidine hydrochloride can be given orally, but it is much more effective when given IM.
A nurse is preparing to give an average-size 9-year-old child a preoperative I.M. injection. Which size needle should the nurse use? 20G, 1″ 20G, 1½″ 22G, 1″ 22G, 1½″
Correct response: 22G, 1″ Explanation: The nurse should evaluate the muscle mass and amount of subcutaneous fat and then select the correct needle size. Without more information, the nurse would select the 22G, 1″ needle, appropriate for an average-size school-age child. The 20G, 1″ needle would be unnecessarily large. The 22G, 1½″ needle would be too long. The 20G, 1½″ needle would be too long and unnecessarily large.
A child with type 1 diabetes is ordered to receive 25 ml/hr of 0.9% I.V. solution. The nurse is using a pediatric microdrip chamber to administer the medication. What is the correct drip rate for this medication? Record your answer using a whole number.
Correct response: 25 Explanation: When using a pediatric microdrip chamber, the number of ml/hr equals the number of gtt/min. If 25 ml/hr is ordered, the I.V. should infuse at 25 gtt/min.
The nurse is administering Rho(D) immune globulin to a pregnant client at 28 weeks' gestation. Which dose would be appropriate for this client? A. 50 mcg in a sensitized client B. 50 mcg in an unsensitized client C. 300 mcg in a sensitized client D. 300 mcg in an unsensitized client
Correct response: 300 mcg in an unsensitized client Explanation: An Rh-negative unsensitized woman should be given 300 mcg of Rho(D) immune globulin at 28 weeks' gestation after an indirect Coombs test verifies that sensitization has not occurred. For a first trimester abortion or ectopic pregnancy, 50 mcg of Rho(D) immune globulin is given. The administration of Rho(D) immune globulin to a sensitized client is not effective.
The nurse is checking the blood sugar level of a pregnant client who is at 33 weeks' gestation. This client has had type 1 diabetes since she was 12 years old. Which fasting glucose value would indicate to the nurse that this client's disease is controlled? A. 45 mg/dl (2.5 mmol/L) B. 85 mg/dl (4.7 mmol/L) C. 120 mg/dl (6.7 mmol/L) D. 136 mg/dl (7.6 mmol/L)
Correct response: 85 mg/dl (4.7 mmol/L) Explanation: The recommended fasting blood sugar level in a pregnant client with diabetes is 60 to 90 mg/dl (3.3 to 5.0 mmol/L). A fasting blood sugar level of 45 mg/dl (2.5 mmol/L) is low, and may result in symptoms of hypoglycemia. A blood sugar level below 120 mg/dl (6.7 mmol/L) is a recommended one-hour postprandial value. A blood sugar level above 136 mg/dl (7.6 mmol/L) in a pregnant client indicates hyperglycemia.
What is the main advantage of using a floor stock system? A nurse can implement medication orders quickly. A nurse receives input from the pharmacist. The system minimizes transcription errors. The system reinforces accurate calculations.
Correct response: A nurse can implement medication orders quickly. Explanation: A floor stock system enables a nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.
A nurse is preparing a teaching plan for a client who was prescribed enalapril maleate for the treatment of hypertension. Which instructions would the nurse include in the teaching plan? Select all that apply. A. Instruct the client to avoid salt substitutes. B. Tell the client that light-headedness is a common adverse effect that does not need to be reported. C. Inform the client of a potential sore throat for the first few days of therapy. D. Advise the client to report facial swelling or difficulty breathing immediately. E. Tell the client that blood tests will be necessary every 3 weeks for 2 months and periodically after that. F. Advise the client not to change the position suddenly to minimize the risk of orthostatic hypotension.
Correct response: A. Instruct the client to avoid salt substitutes. D. Advise the client to report facial swelling or difficulty breathing immediately. F. Advise the client not to change the position suddenly to minimize the risk of orthostatic hypotension. Explanation: The nurse would tell the client to avoid salt substitutes because they may contain potassium, which can cause light-headedness and syncope. Facial swelling or difficulty breathing would be reported immediately because they may be signs of angioedema, which would require discontinuation of the drug. The client would also be advised to change positions slowly to minimize the risk of orthostatic hypotension. The nurse would tell the client to report light-headedness, especially during the first few days of therapy, so dosage adjustments can be made. The client would also report signs of infection, such as sore throat and fever, because the drug may decrease the white blood cell (WBC) count. Because this effect is generally seen within 3 months, the WBC count and differential should be monitored periodically.
The nurse assesses a client who has just received morphine sulfate. The client's blood pressure is 90/50 mm Hg; pulse rate, 58 bpm; and respiration rate, 4 breaths/min. What should the nurse do first? Call the rapid response team. Administer naloxone hydrochloride. Start oxygen at 2 liters/min per nasal cannula. Obtain a stat ECG.
Correct response: Administer naloxone hydrochloride. Explanation: The nurse should first administer naloxone hydrochloride, which is the antidote for morphine sulfate. The signs of overdose on morphine sulfate are a respiration rate of 2 to 4 breaths/min, bradycardia, and hypotension. If the client does not respond, the nurse can call the rapid response team. The client's respirations should improve after receiving the naloxone. Obtaining an ECG is not the first priority for reversing the effects of the morphine.
A toddler taking penicillin for acute otitis media developed a maculopapular rash 24 hours ago after 3 days of therapy. The parents report no other abnormal symptoms. The nurse takes what initial action? Administer epinephrine intramuscularly. Assess chest sounds and oxygen saturation. Administer albuterol (salbutamol) nebulizer. Reassure the parents that this is a mild reaction.
Correct response: Assess chest sounds and oxygen saturation. Explanation: It is relatively common for children to experience delayed hypersensitivity reactions to penicillin that are isolated to cutaneous eruptions. Often, it is safe for these children to receive penicillins in the future. However, the nurse must ensure this current reaction is not more serious than it appears. Because a toddler cannot adequately communicate symptoms, the nurse assesses the client's respiratory status to ensure there is no evidence of bronchoconstriction that could suggest anaphylaxis. Once a full assessment has been completed, the nurse can then request the appropriate treatments be initiated.
After having a total hip replacement, a client receives morphine sulfate by patient-controlled analgesia (PCA) pump. The client says, "This pump doesn't help my pain at all." What should the nurse do in response to this statement? -Assess the client's understanding of the PCA pump. -Tell the physician that the ordered dose isn't sufficient for pain control. -Press the dose delivery button to give the client an immediate dose of the drug. -Push the "Flush" button on the PCA pump to make sure the I.V. line isn't infiltrated.
Correct response: Assess the client's understanding of the PCA pump. Explanation: The nurse should assess the client's understanding of the PCA pump because the client may not correctly understand how to use it. If the client can be taught how to properly use the PCA, other measures may not be necessary. The nurse needs to assess the situation further before notifying the physician. Pressing the dose delivery button can help alleviate the client's pain, but it won't ultimately help if the client doesn't know how to use the pump independently for pain control. Pushing the "Flush" button on the PCA pump will give the client a bolus of the opioid and isn't an appropriate method of assessing the I.V. line's patency.
The nurse is teaching a client with hypertension about taking atenolol. What should the nurse instruct the client to do? Avoid sudden discontinuation of the drug. Monitor the blood pressure annually. Follow a 2-g sodium diet. Discontinue the medication if severe headaches develop.
Correct response: Avoid sudden discontinuation of the drug. Explanation: Atenolol is a beta-adrenergic antagonist indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a prescription. Blood pressure needs to be monitored more frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension.
The client's health care provider prescribes buspirone hydrochloride for increased anxiety. The nurse understands the health care provider's choice of this medication is based on what principle? Buspirone is often administered on an as-needed basis. Buspirone does not have any drug side effects. Buspirone is not habit forming. Buspirone is chemically similar to benzodiazepine medications.
Correct response: Buspirone is not habit forming. Explanation: Buspirone is not habit forming, is administered on a schedule, and does not work immediately. Buspirone may have side effects such as chest pain, dizziness, headache, drowsiness, or nausea. Buspirone hydrochloride is not chemically or pharmacologically related to benzodiazepines or other sedative medications.
A client with active tuberculosis (TB) has been taking combination therapy with daily doses of isoniazid, rifampin, pyrazinamide, and streptomycin for the past month. What information should the nurse reinforce with the client? A. "You should continue to attend the clinic and be observed taking the medication as part of direct observation therapy." B. "Though you feel well now, if you miss any doses, your TB symptoms will become much worse very quickly." C. "Remember that missing even one dose of these medications can make your TB less responsive to treatment." D. "Since you have been treated for a full month, we can now run tests to see if the medication can be stopped."
Correct response: C. "Remember that missing even one dose of these medications can make your TB less responsive to treatment." Explanation: It is essential that the client comply with the combination drug therapy, or resistance will develop, making the TB more difficult to treat. At no time should the client stop taking the medications without the healthcare provider's authorization. If the client was required to attend direct observation therapy, the frequency of dosing would be twice weekly, not daily. Treatment must continue for a minimum of 6 months in most cases, though pyrazinamide may be discontinued after 2 months while the other medications are continued. The client will not feel worse when missing doses, which is one of the reasons adherence of this long-term treatment can be difficult.
A client's caretaker calls the home care nurse and states accidentally puncturing the central venous catheter after discontinuing the total parenteral nutrition. What instructions should the nurse provide to the caretaker? A. Contact 911. B. Clamp the catheter. C. Remove the catheter. D. Position client on left side with head higher than the feet.
Correct response: Clamp the catheter. Explanation: The nurse should instruct the caretaker to clamp the catheter to prevent the client from experiencing an air embolism. The client should be positioned on the left side with head lower than the feet, not higher. The catheter should not be removed by the caretaker; it will need to be removed in an acute care or outpatient setting by a healthcare provider. As the client is not experiencing signs or symptoms of an air embolism or other complication, there is no need to contact 911 at this time.
The nurse is providing care for a child diagnosed with hyperthyroidism. The child has been prescribed propylthiouracil to reduce thyroxine production. How can the nurse best address the potential adverse effects of this medication? A. Encourage small, frequent meals in order to prevent nausea. B. Closely monitor the child's white cell and platelet levels. C. Encourage the use of over-the-counter vitamin D supplements. D. Assess the child's sclerae for signs of jaundice.
Correct response: Closely monitor the child's white cell and platelet levels. Explanation: Thrombocytopenia and leukopenia are adverse effects of propylthiouracil therapy. There is no need for vitamin D supplements, and no added risk of jaundice or nausea.
symptoms after taking antipsychotic medicine. The client reports persistent, uncontrollable restlessness of the limbs and head despite improvement in psychotic symptoms. What is the most appropriate intervention by the nurse? A. Inform the client to ignore these symptoms because they will go away. B. Advise the client to experiment with different dosages to see how that feels. C. Tell the client to go to the emergency room if blurred vision or fever develops. D. Direct the client to see the provider for medication to address these side effects.
Correct response: Direct the client to see the provider for medication to address these side effects. Explanation: Symptoms of tardive dyskinesia include tongue protrusion, lip smacking, chewing, blinking, grimacing, choreiform movements of limbs and trunk, and foot tapping. Primary prevention of tardive dyskinesia is achieved by using the lowest effective dose of a neuroleptic for the shortest time. However, with diseases of chronic psychosis such as schizophrenia, this strategy must be balanced with the fact that increased dosages are more beneficial in preventing recurrence of psychosis. If tardive dyskinesia is diagnosed, the causative drug should be discontinued. Blurred vision is a common adverse reaction of antipsychotic drugs and usually disappears after a few weeks of therapy. Restlessness is associated with akathisia. Sudden fever is a symptom of a malignant neurological disorder. The prescribing provider will make appropriate changes to meet the client's need. Clients should not ignore such symptoms, or adjust their own medication dosage.
What instruction should the nurse include when developing a discharge teaching plan for a client who has been prescribed phenytoin? A. "Take the drug on an empty stomach." B. "You can consume alcoholic beverages in moderation." C. "You can take any phenytoin brand because all brands are the same." D. "Don't stop taking the drug except with medical supervision."
Correct response: Don't stop taking the drug except with medical supervision." Explanation: Abrupt cessation of phenytoin may trigger status epilepticus, so the client should be warned not to stop the drug unless approved by the provider. Taking phenytoin with food minimizes GI distress. Alcoholic beverages can decrease the drug's effectiveness. Changing phenytoin brands may alter the therapeutic effect.
The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. What should the nurse do? A. Allow the client to keep the eye drops at the bedside and use as prescribed on the bottle. B. Place the eye drops in the hospital medication drawer and administer as labeled on the bottle. C. Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital. D. Ask the client's wife to assist the client in administering the eye drops while the client is in the hospital.
Correct response: Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital. Explanation: In order to prevent medication errors, clients may not use medications they bring from home; the HCP will prescribe the eye drops as required. It is not safe to place the eye drops in the client's medication box or to permit the client to use them at the bedside. The nurse should ask the wife to take the eye drops home.
A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus? -Gently aspirate the I.V. catheter to check for a blood return. -Insert a second I.V. line into the opposite arm. -Warm the I.V. medication to room temperature. -Place a tourniquet on the arm in which the injection will be administered.
Correct response: Gently aspirate the I.V. catheter to check for a blood return. Explanation: Before administering an I.V. bolus, the nurse should gently aspirate the I.V. catheter for a small amount of blood to ensure correct placement of the I.V. catheter. Then the nurse may inject the medication over the recommended time interval. The nurse doesn't need to insert another I.V. line unless the ordered medication is incompatible with the medication in the I.V. solution. Warming the medication could alter the drug's action. Placing a tourniquet on the arm would close off the venous system and prevent drug injection.
The nurse attempts to obtain a blood specimen from an implanted port. The port does not have blood return. What should the nurse do next? Remove the implanted port. Send the client to get a chest x-ray. Have the client change positions. Change the dressing on the implanted port.
Correct response: Have the client change positions. Explanation: If an implanted port does not have blood return, having the client change position, performing the Valsalva maneuver, and raising or lowering the head of the bed can promote blood return. The port should not be removed; the access needle may need to be removed and reinserted depending on the facility policy. A chest x-ray may be required but is not what the nurse should do first. Changing the dressing may not help with blood return.
A young adult client comes to the clinic in an agitated state. The client's friends report that the client has been consuming beverages combining energy drinks and alcohol all day. What is the priority action by the nurse in caring for this client's immediate needs? A. Verify that the client consumed energy drinks and alcohol all day. B. Hydrate the client, and monitor laboratory results and vital signs. C. Contact the client's next of kin for consent of treatment. D. Consider an illicit drug screening panel.
Correct response: Hydrate the client, and monitor laboratory results and vital signs. Explanation: The nurse should recognize that the client is most likely in an alcohol- and caffeine-intoxicated state. It is important to determine baseline laboratory results, monitor vital signs, and begin hydration to aid in dilution of the intoxicating agents. Verifying consumption of drinks and alcohol and an illicit drug screening panel are important but not the priorities for care. Contacting the client's next of kin is important in care but not a priority if the client needs treatment.
A nurse is teaching a client with bipolar disorder about the drug carbamazepine. The nurse determines teaching was effective when the client states A. "My hair will fall out after I take this drug for a few months." B. "I will drink plenty of water so I don't develop kidney problems." C. I need to have my blood counts checked periodically." D. "I can't take any other drugs while I am taking this one."
Correct response: I need to have my blood counts checked periodically." Explanation: The most dangerous adverse effect of carbamazepine is bone marrow depression. Other medications may be taken with carbamazepine. Hair loss doesn't occur in clients taking carbamazepine. Clients who take lithium, not carbamazepine, must be closely monitored for nephrogenic diabetes insipidus. The interactions of all drugs must be monitored because some can either increase or decrease the blood level of carbamazepine.
A client who received massive packed red blood cell (PRBC) blood transfusions due to trauma has a potassium level of 7.1 mEq/L (7.1 mmol/L). Which medication should the nurse expect to administer? A. I.V. insulin B. I.V. potassium chloride C. oral spironolactone D. oral lisinopril
Correct response: I.V. insulin Explanation: The client is experiencing transfusion-associated hyperkalemia. Storing packed red blood cell increases the potassium concentration. I.V. regular insulin pushes potassium from the blood into the cell decreasing the serum potassium level. Severe cases require hemodialysis. I.V. potassium chloride and spironolactone, a potassium-sparing diuretic, will further increase the potassium. Angiotensin-converting enzyme (ACE) inhibitor such as lisinopril causes hyperkalemia.
The student nurse is planning to care for a peripheral intravenous (I.V.) site for a client receiving chemotherapy. Which outcome would demonstrate that the student understands the concepts of I.V. care? A. Clean the insertion site and change the dressing every 72 hours. B. Periodically flush the catheter with heparin to maintain its flow of I.V. solution. C. Monitor for redness, drainage, and swelling at the insertion site every 24 hours. D. If extravasation is suspected, stop the infusion.
Correct response: If extravasation is suspected, stop the infusion. Explanation: Peripheral venous access devices are commonly used for clients receiving long-term chemotherapy, total parenteral nutrition, or frequent medication or fluids. These devices may remain in place for several weeks to more than 1 year if no complications develop. Extravasation, or infiltration of the drug into surrounding tissue, is an emergency, and the priority action is to stop the infusion. The site could be cleaned and dressing changed more often than every 72 hours depending on the type of dressing, patient's condition, and other factors. Heparin is not used to flush peripheral sites. Nurses monitor I.V. sites more frequently than every 24 hours; the site should be checked at least every 4 hours.
Which technique is correct when administering a subcutaneous injection? A. Use a 1-inch (2.5-cm) needle for injection. B. Insert the needle at a 45-degree angle to the skin. C. Spread the skin tightly at the injection site. D. Draw 0.2 ml of air into the syringe before administration.
Correct response: Insert the needle at a 45-degree angle to the skin. Explanation: Subcutaneous injections are administered at an angle of 45 to 90 degrees, depending on the size of the client. Subcutaneous needles are typically to 1/2 to 5/8 inches (1.3 to 1.6 cm) in length. The skin should be pinched up at the injection site to elevate the subcutaneous tissue. Air is not drawn into the syringe for a subcutaneous injection.
The nurse observes a new parent give an oral medication to a 4-month-old infant. The parent instills the medication directly in the back of the infant's throat. Which choice is the nurse's best action? A. Instruct the parent to instill a small amount of the medication inside the baby's cheek. B. Praise the parent's technique of giving the medication. C. Have the parent lay the infant flat, restraining the arms, while giving the medication. D. Demonstrate to the parent ways to prop the infant in a sitting position for medication administration.
Correct response: Instruct the parent to instill a small amount of the medication inside the baby's cheek. Explanation: The parent's technique of instilling the medication in the back of the throat is not correct and could cause the infant to choke. The nurse should instruct the parent to instill a small amount at a time inside the infant's cheek. The parent should hold an infant in the bottle-feeding position when administering an oral medication by placing the child's inner arm behind the back, supporting the head in the crook of the elbow, and holding the child's free hand with the hand of the supporting arm. Propping a 4-month-old infant is not appropriate. The infant cannot sit unsupported even in a seated position. Administering medication to an infant lying flat could cause choking and aspiration.
What information should the nurse provide to the client who is receiving warfarin? A. Partial thromboplastin time values determine the dosage of warfarin sodium. B. Protamine sulfate is used to reverse the effects of warfarin sodium. C. International Normalized Ratio (INR) is used to assess effectiveness. D. Warfarin sodium will facilitate clotting of the blood.
Correct response: International Normalized Ratio (INR) is used to assess effectiveness. Explanation: INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots.
The nurse will assist with the sedation procedure for a client who is undergoing an ankle reduction. Which medication should the nurse prepare? Ketamine Glyburide Rocuronium Succinylcholine
Correct response: Ketamine Explanation: Ketamine is a common medication used for procedures that require moderate sedation, such as an ankle reduction. Glyburide is a sulfonylurea hypoglycemic oral medication used for treating diabetes. Rocuronium and succinylcholine are neuromuscular blocking agents and would not be used in moderate sedation; they cause paralysis and the client would become apneic, requiring immediate airway management.
A client presents with severe headache, blurred vision, anxiety and confusion. The client's blood pressure is 224/137 mm Hg. The family reports that the client has hypertension, but has not been taking the prescribed blood pressure medications. The nurse anticipates giving which medication? Norepinephrine Amiodarone Methotrexate Labetalol
Correct response: Labetalol Explanation: This client is showing signs and symptoms of a hypertensive crisis, or hypertensive emergency, and the nurse should anticipate treatment/medications to lower the blood pressure. Labetalol is a beta-blocker medication given intravenously that is often a first-line treatment for hypertensive crisis. Norepinephrine is not indicated for this client as it is a vasopressor and increases blood pressure. Amiodarone is given for cardiac arrythmias and would not help lower blood pressure. Methotrexate is an antineoplastic medication used for treating various cancers and severe rheumatoid arthritis.
When preparing the teaching plan for a client about lithium therapy, the nurse should provide which instruction to the client concerning sodium? Maintain an adequate sodium intake. Discontinue sodium in the diet. Buy foods labeled "low in sodium." Increase sodium in the diet.
Correct response: Maintain an adequate sodium intake. Explanation: The nurse would teach the client taking lithium and his family about the importance of maintaining adequate sodium intake to prevent lithium toxicity. Because lithium is a salt, reduced sodium intake could result in lithium retention with subsequent toxicity. Increasing sodium in the diet is not recommended and may be harmful. Increased sodium levels result in lower lithium levels. Therefore, the drug may not reach therapeutic effectiveness.
What is the most important information for the nurse to include when teaching a client about metronidazole? A. Breathlessness and cough are common adverse effects. B. Urine may develop a greenish tinge while the client is taking this drug. C. Mixing this drug with alcohol causes severe nausea and vomiting. D. Heart palpitations may occur and should be immediately reported.
Correct response: Mixing this drug with alcohol causes severe nausea and vomiting. Explanation: When mixed with alcohol, metronidazole causes a disulfiram-like effect involving nausea, vomiting, and other unpleasant symptoms. Urine may turn reddish brown, not greenish, from the drug. Cardiovascular or respiratory effects are not associated with this drug.
After suffering an acute myocardial infarction (MI), a client with a history of type 1 diabetes is prescribed metoprolol intravenously. Which nursing interventions are associated with intravenous administration of metoprolol? Select all that apply. A. Monitor glucose level closely. B. Monitor for heart block and bradycardia. C. Monitor blood pressure closely. D. Mix the drug in 50 ml of dextrose 5% in water and infuse over 30 minutes. E. Be aware that the drug is not compatible with morphine.
Correct response: Monitor glucose level closely. Monitor for heart block and bradycardia. Monitor blood pressure closely. Explanation: Metoprolol masks the common signs of hypoglycemia; therefore, glucose levels would be monitored closely in diabetic clients. When used to treat an MI, metoprolol is contraindicated in clients with heart rates less than 45 beats/minute and any degree of heart block, so the nurse would monitor the client for bradycardia and heart block. Metoprolol masks common signs and symptoms of shock, such as decreased blood pressure, so blood pressure would also be monitored closely. The nurse would give the drug undiluted by direct injection. Although metoprolol would not be mixed with other drugs, studies have shown that it is compatible when mixed with morphine sulfate or when administered with alteplase infusion at a Y-site connection.
A client develops hepatic encephalopathy 1 week after portal caval shunt surgery. The client's physician orders neomycin, 4 g by mouth daily in four divided doses. The client's partner asks how neomycin decreases the serum ammonia concentration. How should the nurse respond? A. Neomycin decreases the amount of ammonia-producing bacteria in the GI tract. B. Neomycin acidifies the colon and traps ammonia in the GI tract. C. Neomycin binds with ammonia in the GI tract. D. Neomycin increases the growth of such bacteria as Escherichia coli.
Correct response: Neomycin decreases the amount of ammonia-producing bacteria in the GI tract. Explanation: Neomycin lowers the blood ammonia level by reducing the quantity of ammonia-producing bacteria in the GI tract. The drug also exerts its antibacterial activity directly on the ribosomes of susceptible organisms, among them E. coli, by inhibiting protein synthesis via direct action on ribosomal subunits. When present, these bacteria convert urea to ammonia. Neomycin is bactericidal in high concentrations and bacteriostatic in low concentrations. Thus, it doesn't trap or bind with ammonia in the GI tract.
A nurse is reviewing a client's medical record and notes that the health care provider has prescribed furosemide 400 mg orally twice a day. What will be the best action by the nurse? A. Ask the client about the usual prescribed medication dose and reason for the prescription. B. Recheck the medication formulary for the usual drug dosage. C. Notify the health care provider about the concern for the prescribed dose. D. Notify the nurse manager of the erroneous prescription and complete an incident report.
Correct response: Notify the health care provider about the concern for the prescribed dose. Explanation: The nurse is responsible for clarifying any prescription for a medication prescribed outside the normal dose. The usual dose for furosemide is 20 to 80 mg. Therefore, the nurse needs to contact the health care provider to ensure what has been prescribed is indeed correct. There may be a valid reason for the specific dosage prescribed even though it is outside the usual range. Asking the client about the medication is an option, but the nurse needs to confirm the prescribed dose with the health care provider. Although rechecking the formulary for the usual dosage would help to support the nurse's concerns, any prescription that is in question needs to be clarified. Notifying the nurse manager and filing an incident report would not be necessary. It is the nurse's responsibility to clarify the prescription.
A client reports a dry mouth two days after starting therapy with trihexyphenidyl for Parkinson disease. What is the best action by the nurse? A. Offer the client ice chips and frequent sips of water. B. Withhold the medication and notify the provider. C. Change the client's diet to clear liquid until the symptoms subside. D. Encourage the use of supplemental puddings and shakes to maintain weight.
Correct response: Offer the client ice chips and frequent sips of water Explanation: Trihexyphenidyl is an anticholinergic agent that causes blurred vision, dry mouth, constipation, and urinary retention. There is no need to withhold the drug unless hypotension or tachyarrhythmia occurs. A clear liquid diet isn't indicated at this time. It doesn't provide adequate nutrition, and may be more difficult to swallow than thickened liquids if dysphagia is present. Although weight loss may occur with Parkinson's disease, it is not a side effect of trihexyphenidyl.
The nurse is assessing for blood return from a client's implanted port. Which nursing intervention is appropriate to assure that the needle will be flushed with pure saline? Wash hands before and after the procedure. Draw the smallest amount of blood required for the sample. Prevent blood from entering the saline flush syringe. Flush with heparin after drawing the sample.
Correct response: Prevent blood from entering the saline flush syringe. Explanation: To assure that the needle will be flushed with pure saline, the nurse does not allow blood to enter the saline flush syringe when assessing for blood return from an implanted port. Washing hands prevents contamination, drawing the least amount of blood prevents overwasting, and flushing with heparin prevents clots.
The nurse and occupational therapist are planning an outdoor volleyball game and picnic for eight mental health clients. What action should the nurse take for the two clients taking nortriptyline for depression? Be aware that this drug can cause hypotension. Recognize that these clients may experience excessive thirst. Omit the morning dose on the day of the picnic. Provide protective clothing and apply sunscreen before going out.
Correct response: Provide protective clothing and apply sunscreen before going out. Explanation: A common adverse effect of this drug is sensitivity to the sun. Protective clothing and sunscreen should be worn while the client is exposed to sunlight.
A 20-month-old toddler has been treated with permethrin for scabies. The toddler's parent asks, "Is this medication working? My child is still itching." Which response by the nurse is most appropriate? A. Stop treatment because the drug isn't safe for children under age 2. B. Pruritus can be present for weeks after treatment. C. Apply the drug every day until the rash and itching disappear. D. Pruritus is common in children under age 5 treated with permethrin.
Correct response: Pruritus can be present for weeks after treatment. Explanation: Pruritus may be present for weeks following treatment with permethrin. The drug is safe for use in infants as young as age 2 months. Treatment with permethrin can be safely repeated in 2 weeks. Pruritus is caused by secondary reactions of the mites.
A client with a subarachnoid hemorrhage is prescribed a 1,000 mg loading dose of I.V. phenytoin. What information is most important when administering this dose? A. Therapeutic drug levels should be maintained between 20 and 30 mg/ml. B. Rapid phenytoin administration can cause cardiac arrhythmias. C. Phenytoin should be mixed in dextrose in water before administration. D. Phenytoin should be administered through an I.V. catheter in the client's hand.
Correct response: Rapid phenytoin administration can cause cardiac arrhythmias. Explanation: Intravenous phenytoin should not exceed 50 mg/min, as rapid administration can depress the myocardium, causing lethal dysrhythmias. Therapeutic drug levels range from 10 to 20 mg/ml. Phenytoin is only compatible with normal saline, not dextrose in water. Phenytoin is very irritating to the blood vessels, and may cause purple glove syndrome when administered I.V. into a hand.
Which action is a priority for the nurse when finding medications at a client's bedside? A. Leave the medications, as the client will take them after the next meal. B. Leave the medications and seek the nurse who left them in the room. C. Remove the medications from the room and discard them into an appropriate disposal bin. D. Label the medications and place them back in the medication room.
Correct response: Remove the medications from the room and discard them into an appropriate disposal bin. Explanation: Disposing of the medications in the appropriate manner reflects best practice of nursing and medication administration. Leaving the medications by the client's bed would create a risk for another client to take them, for this client to take them inappropriately, or for them to get lost. It would be incorrect and unsafe to label medications that were taken out by another nurse.
The client was found not breathing and was transported to the hospital. A family member states the client may have taken too much pain medication because the client frequently forgets if the medication was taken. Which observation(s) by the nurse indicates therapeutic effect of naloxone hydrochloride in the client? Select all that apply. Reverses decreased respiratory rate of 10. Reverses decreased level of consciousness. Increases nerve pain. Reverses blood pressure of 90/58. Increases inflammation.
Correct response: Reverses decreased respiratory rate of 10. Reverses decreased level of consciousness. Reverses blood pressure of 90/58. Explanation: Therapeutic effect includes reversal of respiratory depression, sedation, and hypotension. Therapeutic effect does not include increasing nerve pain or increasing inflammation.
Which principle should a nurse consider when administering pain medication to a client? A. Use opioid combination drugs or nonopioid analgesics only for severe pain. B. I.V. pain medications may take as long as 2 hours to relieve pain. C. Sustained-release oral formulations should be given around the clock, if possible, for control of chronic pain. D. Morphine and hydromorphone shouldn't be used to treat severe pain.
Correct response: Sustained-release oral formulations should be given around the clock, if possible, for control of chronic pain. Explanation: Administering sustained-release oral formulations around the clock provides better relief of chronic pain by keeping blood levels within therapeutic range. Opioid combination drugs and nonopioid medications are most effective in the treatment of mild to moderate pain. I.V. medications usually act within 1 hour of administration. Morphine and hydromorphone are drugs of choice for severe pain.
A client is 2 days post small bowel resection with a placement of an ostomy in the right lower quadrant. The nurse is teaching the client to apply an ostomy appliance to the client's abdomen. Which client action would indicate to the nurse that the teaching was successful? A. The client trims the faceplate opening giving the stoma a 1-inch (2.5 cm) border around the stoma. B. The client assesses the stoma and the surrounding skin before placing the new appliance. C. The client chooses an antibacterial soap to scrub the fecal material around the stoma. D. The client states that the faceplate should be changed every other day.
Correct response: The client assesses the stoma and the surrounding skin before placing the new appliance. Explanation: For a client with an ostomy, maintaining skin integrity is a priority. The client should inspect the area with each appliance change for skin integrity issues. The client should gently wash the area surrounding the stoma using a facecloth and mild soap. Scrubbing the area around the stoma can damage the skin and cause bleeding. The faceplate opening should be no more than 1/8 inch (.3175 cm) to 1/6 inch (.4233 cm) larger than the stoma. This size protects the skin from exposure to irritating fecal material. The client should change the appliance every 3 to 7 days. It is important to create an adequate seal and prevent leakage of fecal material from under the faceplate by applying a thin layer of skin barrier and smoothing out wrinkles in the faceplate.
An infection control nurse has identified a problem related to infection control procedures on a medical unit that has a high census of clients diagnosed with tuberculosis. The nurse has decided to conduct an in-service education program for the staff about the required transmission-based precautions. The nurse determines that the program was successful based on which statement by the staff? A. "The client needs to be placed in a private, negative air pressure room." B. "If the client needs to be transported, transport personnel need to wear a mask." C. "When wearing a respirator, it needs to be removed before leaving the client's room." D. "It is okay to leave the client's room door open to allow for interaction with the staff."
Correct response: The client needs to be placed in a private, negative air pressure room." Explanation: A client with tuberculosis should be on airborne precautions. This includes using a private, negative air pressure room, transporting the client as little as possible, having the client wear a mask if the client is being transported out of the room, removing the respirator after leaving the client's room, and keeping the client's room door shut.
A client experiencing alcohol withdrawal is prescribed lorazepam. The client's family asks the nurse about the purpose of the medication. What is the nurse's best response? A. The medication can help your family member relax and sleep. B. The lorazepam will reduce the your family member's symptoms of withdrawal. C. This medication will reduce your family member's cravings for alcohol. D. Lorazepam is a type of benzodiazepine medication.
Correct response: The lorazepam will reduce the your family member's symptoms of withdrawal. Explanation: Lorazepam is a short-acting benzodiazepine usually given for 1 week to ease the effects of alcohol withdrawal. It is not used to reduce cravings and, although it will help the client feel more relaxed and can enhance sleep, this is not the primary indication. Though it is a benzodiazepine, telling the family this information does not address the question of why the client has been prescribed this medication.
A client with bipolar disorder tells the nurse that she just found out she is pregnant, and is concerned because she takes lithium. What is the most important information for the nurse to provide to this client? A. Use of lithium usually results in serious congenital problems. B. Thyroid problems can occur in the first trimester of the pregnancy. C. Lithium causes severe urine retention and increased risk of toxicity. D. Women who take lithium are very likely to have a spontaneous abortion.
Correct response: Use of lithium usually results in serious congenital problems. Explanation: Use of lithium during pregnancy will result in congenital defects, especially cardiac defects. Thyroid problems don't occur in the first trimester of the pregnancy. In lithium toxicity, a condition called nontoxic goiter may occur. An adverse effect of lithium is polyuria, not urine retention. The rate of spontaneous abortion for women taking lithium is no greater than for nonusers.
A nurse has an order to administer an I.M. injection of iron dextran to a client. Which action is correct for an I.M. injection? Insert the needle at a 45-degree angle. Massage the injection site immediately after injection. Pull the skin laterally toward the injection site. Withdraw the needle and release the skin.
Correct response: Withdraw the needle and release the skin. Explanation: I.M. iron dextran should be given by intramuscular injection using a z-tract technique. When giving an I.M. injection using the z-track technique, the nurse pulls the skin laterally away from the injection site, inserts the needle at a 90-degree angle, waits 10 seconds after injecting the medication, and then withdraws the needle and releases the skin. No massage is used with a z-tract injection.
The nurse should advise which client who is taking lithium to consult with the health care provider regarding a potential adjustment in lithium dosage? a client who continues work as a computer programmer a client who attends college classes a client who can now care for her children a client who is beginning training for a tennis team
Correct response: a client who is beginning training for a tennis team Explanation: A client who is beginning training for a tennis team would most likely require an adjustment in lithium dosage because excessive sweating can increase the serum lithium level, possibly leading to toxicity. Adjustments in lithium dosage would also be necessary when other medications have been added, when an illness with high fever occurs, and when a new diet begins.
The postoperative nursing assessment of a client's ability to swallow fluids before providing oral fluids is based on the type of anesthesia given. Which client would not have delayed fluid restrictions? The client who had: A. undergone a bronchoscopy under local anesthesia. B. a transurethral resection of a bladder tumor under general anesthesia. C. a repair of carpal tunnel syndrome under local anesthesia. D. an inguinal herniorrhaphy with spinal and intravenous conscious sedation.
Correct response: a repair of carpal tunnel syndrome under local anesthesia. Explanation: The client who has not had the gag reflex anesthetized is the client who had a repair of the carpal tunnel syndrome under local anesthesia because the area being anesthetized was the tissue in the wrist. The client who had a bronchoscopy received a local anesthetic on the vocal cords, and the nurse should check the gag reflex or ability to swallow before administering fluids. Clients who had general anesthesia or intravenous conscious sedation received medication for central nervous system sedation, and the nurse should assess the level of consciousness and ability to swallow before administering fluids.
After a thyroidectomy, the client develops a positive Trousseau's sign. What is the nurse's priority action? administer levothyroxine therapy administer liothyronine therapy administer potassium. chloride administer calcium gluconate
Correct response: administer calcium gluconate Explanation: Damage to the parathyroid glands can inadvertently occur during a thyroidectomy. This may cause a decrease in serum calcium, which causes muscle hyperexcitability and tetany. The treatment for a client who develops hypocalcemia and tetany following a thyroidectomy is calcium gluconate. Hypokalemia does not cause a positive Trousseau's sign. Decreased thyroid hormones will not cause tetany, however, the client will have to take thyroid replacement therapy following a thyroidectomy.
The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which would most likely contribute to the achievement of this goal? implementing relaxation exercises administering a sedative as needed providing a soft, bland diet administering famotidine as ordered
Correct response: administering famotidine as ordered Explanation: Clients with burns are susceptible to the development of Curling's ulcer, a gastroduodenal ulcer that is caused by a generalized stress response. The stress response results in increased gastric acid secretion and a decreased production of mucus. Prevention is the best treatment, and clients are frequently treated prophylactically with antacids and H2 histamine blockers such as famotidine.
A client is prescribed adenosine for treatment of supraventricular tachycardia (SVT). When should the nurse assess the client for a response to the dose of adenosine? after 15 to 20 minutes after 1 to 2 minutes after 30 minutes after 5 to 10 minutes
Correct response: after 1 to 2 minutes Explanation: Adenosine is the first-line medication for SVT, and can convert the heart rhythm to a normal rate and rhythm. It is given as an emergent medication and should be delivered as rapid intravenous (IV) bolus over 1 to 2 seconds. It should be administered at the peripheral IV site that is closest to the client's core. Once administered, the IV site should be flushed with 20 ml of normal saline immediately. The client's response is known within 1 to 2 minutes of administration, at which time the cardiac rhythm will dictate if the dose needs to be repeated. Waiting longer than 2 minutes to assess the response would delay potentially life-saving treatment.
In order for pravastatin to have maximum effect, the nurse should administer this medication: early in the morning prior to breakfast. 2 hours after the afternoon meal. at bedtime. with breakfast.
Correct response: at bedtime. Explanation: Cholesterol is manufactured in the liver just after midnight each day; therefore, statin medications are best taken just before bedtime. Remediation:
In order for pravastatin to have maximum effect, the nurse should administer this medication: A. early in the morning prior to breakfast. B. 2 hours after the afternoon meal. C. at bedtime. D. with breakfast.
Correct response: at bedtime. Explanation: Cholesterol is manufactured in the liver just after midnight each day; therefore, statin medications are best taken just before bedtime.
Where is the best site for the nurse to assess a client's pulse prior to administering digoxin? A. inner aspect of right wrist at the base of the thumb B. at the left fifth intercostal space, midclavicular line C. the anterior aspect of the right arm at the antecubital fossa D. the left second intercostal space in the midclavicular line
Correct response: at the left fifth intercostal space, midclavicular line Explanation: The administration of digoxin requires the assessment of the client's apical pulse. The correct landmark for obtaining an apical pulse is the left fifth intercostal space at the midclavicular line. This is the point of maximum impulse, and the location of the left ventricular apex. The left second intercostal space in the midclavicular line is where pulmonic sounds are auscultated.
One hour after receiving pyridostigmine bromide for myasthenia gravis, a client reports difficulty swallowing and excessive respiratory secretions. What medication would the nurse anticipate to reverse the effects of pyridostigmine bromide? A. additional pyridostigmine bromide B. atropine C. edrophonium D. acyclovir
Correct response: atropine Explanation: These symptoms suggest cholinergic crisis or excessive acetylcholinesterase medication, typically appearing 45 to 60 minutes after the last dose of acetylcholinesterase inhibitor. Atropine, an anticholinergic drug, is used to antagonize acetylcholinesterase inhibitors. The other drugs are acetylcholinesterase inhibitors. Edrophonium is used for diagnosis, and pyridostigmine bromide is used to treat myasthenia gravis and would worsen these symptoms. Acyclovir is an antiviral and would not be used to treat these symptoms.
A client is receiving opioid epidural analgesia. The nurse should notify the health care provider (HCP) if the client has which findings? Select all that apply. A. blood pressure of 80/40 mm Hg and baseline blood pressure of 110/60 mm Hg B. respiratory rate of 14 breaths/minute and baseline respiratory rate of 18 breaths/minute C. report of crushing headache D. minimal clear drainage on the dressing E. pain rating of 3 on a scale of 1 to 10
Correct response: blood pressure of 80/40 mm Hg and baseline blood pressure of 110/60 mm Hg report of crushing headache minimal clear drainage on the dressing Explanation: A drop in blood pressure to 80/40 mm Hg is significant and should be reported to the HCP. Hypotension and vasodilation may occur as a result of sympathetic nerve blockage along with the pain nerve blockage. A report of a crushing headache suggests that the epidural catheter may be dislodged in the subarachnoid space rather than the epidural space. Epidural dressings should remain dry and intact. The presence of clear fluid on the dressing could indicate a cerebral spinal fluid leak or the leakage of medication. A respiratory rate of 14 breaths/min, although somewhat decreased from baseline, is within acceptable parameters. However, if the rate drops to 10 breaths/min or less, the HCP should be notified. A pain rating of 3 out of 10 suggests that pain is being relieved with the epidural analgesia.
The home health nurse is assessing a client and determines that the client has an unsteady gait. The client reports a history of falls. Which nursing action represents an advocacy role for the home health nurse? A. contacting a health care equipment resource to rent a walker for the client B. to use listening to a client express feelings of frustration over increasing limitations C. instructing the client to contact a senior day care service D. reassuring the client that using a walker will prevent falls in the future
Correct response: contacting a health care equipment resource to rent a walker for the client to use Explanation: Referral to community agencies is an advocacy role for home health nurses. The role of the advocate implies the home care nurse is able to advise clients how to find alternative sources of care. Giving emotional support, giving therapies to clients, and instructing clients about other resources are direct care activities. Reassuring the client is superficial, and using a walker may not prevent falls in the future.
The client is receiving an IV infusion of 5% dextrose in normal saline running at 125 ml/h. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first: discontinue the infusion. apply a warm soak to the site. stop the flow of solution temporarily. irrigate the needle with normal saline.
Correct response: discontinue the infusion. Explanation: Signs of infiltration include slowing of the infusion and swelling, pain, hardness, pallor, and coolness of the skin at the site. If these signs occur, the IV line should be discontinued and restarted at another infusion site. The new anatomic site, time, and type of cannula used should be documented. The nurse may apply a warm soak to the site, but only after the IV line is discontinued. Parenteral administration of fluids should not be stopped intermittently. Stopping the flow does not treat the problem, nor does it address the client's needs for fluid replacement. Infiltrated IV sites should not be irrigated; doing so will only cause more swelling and pain.
Which nursing intervention would help to decrease the adverse effects of radiation therapy on the gastrointestinal tract? A. avoiding the use of antispasmodics B. encouraging fluids and a soft diet C. giving antiemetics when vomiting occurs D. avoiding mouthwashes to prevent irritation of mouth ulcers
Correct response: encouraging fluids and a soft diet Explanation: Radiation therapy can cause adverse effects such as nausea and vomiting, anorexia, mucosal ulceration, and diarrhea. Antispasmodics are used to help reduce diarrhea. Encouraging fluids and a soft diet will help with anorexia. Antiemetics should be given before the onset of vomiting. Frequent mouthwashes are indicated to prevent mycosis.
A depressed client has been taking a selective serotonin reuptake inhibitor (SSRI) in the evening, and is upset because he cannot perform sexually due to erectile problems. What is the nurse's best response? stop taking the drug and notify the prescriber engage in sexual activity prior to taking the drug monitor for low blood pressure on a daily basis take the drug with food or 8 oz of water
Correct response: engage in sexual activity prior to taking the drug Explanation: A viable option is for the client to engage in sexual activity before taking his daily antidepressant medication. It is not appropriate to suggest stopping the medication. Monitoring the client's blood pressure and taking the drug with food or 8 oz of water will not address the erectile dysfunction experienced by the client.
The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site has which appearance? minimal leaking no swelling tissue pallor evidence of a bleb
Correct response: evidence of a bleb Explanation: A properly administered intradermal injection shows evidence of a bleb at the injection site. There should be no leaking of medication from the bleb; it needs to be absorbed into the tissue. Lack of swelling at the injection site means that the injection was given too deeply. The presence of tissue pallor does not indicate that the injection was given correctly.
Liquid oral iron supplements have been prescribed for a child. What is the most important information for the nurse to provide to this child's parents? give the supplements with food stop the medication if vomiting occurs decrease the dose if constipation occurs give the medicine via a dropper or through a straw
Correct response: give the medicine via a dropper or through a straw Explanation: Liquid iron preparations may temporarily stain the teeth. The drug should be given by dropper or through a straw. Iron supplements should be given between meals, when the presence of free hydrochloric acid is greatest. If vomiting occurs, supplementation should not be stopped, but it should be administered with food. Constipation can be decreased by increasing intake of fruits and vegetables.
The health care provider has prescribed salicylates for an older adult client with osteoarthritis to relieve pain. The nurse knows to assess the client for what potential adverse reaction? hearing loss increased pain in joints decreased calcium absorption increased bone demineralization
Correct response: hearing loss Explanation: Many older adults already have diminished hearing, and salicylate use can lead to further or total hearing loss. Salicylates do not increase pain in joints, decrease calcium absorption, or increase bone demineralization.
Which assessment finding is expected in a client receiving bicalutamide and leuprolide for advanced prostate cancer? A. abdominal distention B. acromegaly C. colicky pain D. hot flashes
Correct response: hot flashes Explanation: Bicalutamide, a nonsteroidal antiandrogen, and leuprolide, a gonadotropin-releasing hormone agonist, decrease the production of testosterone. This helps decrease the production of cancer cells involved in prostate cancer. Because androgens are responsible for the development of male genitalia and secondary male sex characteristics, low androgen levels can cause genital atrophy, breast enlargement, and hot flashes. Abdominal distention, acromegaly, and colicky pain aren't caused by bicalutamide and leuprolide therapy.
A nurse is reviewing the healthcare provider's orders for a client admitted with systemic lupus erythematosus (SLE). Which medication would the nurse expect to find in this client's plan of care? morphine ketoconazole hydroxychloroquine dimenhydrinate
Correct response: hydroxychloroquine Explanation: Fatigue, photosensitivity and a "butterfly" rash on the face are all signs and symptoms of SLE. Hydroxychloroquine is used in the treatment of SLE to prevent inflammation. Pharmacological treatment of SLE also involves nonsteroidal anti-inflammatory drugs, corticosteroids, and immunosuppressive agents. Morphine is an opioid analgesic, ketoconazole is an antifungal agent, and dimenhydrinate is an antiemetic.
A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale had been prescribed a loop diuretic to treat peripheral edema. The nurse should monitor the client closely for what side effect of loop diuretic therapy that could worsen the client's hypercapnia? hypokalemia hyponatremia orthostatic hypotension hyperuricemia
Correct response: hypokalemia Explanation: All the options offered are potential side effects of loop diuretics, but only hypokalemia would directly pose the risk for increasing hypercapnia. When potassium levels are low, hydrogen ions shift into the intracellular space to liberate potassium into the extracellular space, and this contributes to metabolic alkalosis. To compensate for metabolic alkalosis, hypoventilation occurs in an attempt to retain carbon dioxide (the respiratory acid) and decrease the client's pH. Therefore, hypokalemia can worsen hypercapnia. Diuretics must be used with caution in clients with COPD. However, diuretics may be prescribed to treat peripheral edema that results from right ventricular dysfunction and the resulting systemic venous congestion.
The nurse is preparing to administer I.V. insulin to a client diagnosed with diabetic ketoacidosis (DKA). What will the nurse monitor while the client is receiving this intervention? hypokalemia and hypoglycemia hypocalcemia and hyperkalemia hyperkalemia and hyperglycemia hypernatremia and hypercalcemia
Correct response: hypokalemia and hypoglycemia Explanation: The nurse should monitor for decreased potassium and decreased glucose. Hypoglycemia might occur if too much insulin is administered, or insulin is administered too quickly. Intravenous insulin forces potassium into cells, thereby lowering plasma levels of potassium. The client may have hyperkalemia prior to starting the insulin therapy, but hypokalemia will occur with insulin administration. Calcium and sodium levels should not be affected.
A client is experiencing status asthmaticus. For which would the nurse anticipate an immediate order? inhaled Beta-2 adrenergic agonist inhaled corticosteroids I.V. beta-adrenergic agents oral corticosteroids
Correct response: inhaled Beta-2 adrenergic agonist Explanation: Inhaled beta-adrenergic agonists agents are the first line of therapy in status asthmaticus, as they help promote bronchodilation, which improves oxygenation. I.V. beta-adrenergic agents can be used, but must be carefully monitored because of their systemic effects. They are typically used when the inhaled beta-adrenergic agents do not work. Inhaled and oral corticosteroids are slow-acting, and their use won't reduce hypoxia in the acute phase.
A team of nurses is preparing a trauma room for the arrival of a child with partial-thickness burns to both lower extremities and portions of the trunk. Which intravenous fluid should the nurse be prepared to administer to this client? A. albumin B. dextrose 5% and half-normal saline C. lactated Ringer's solution D. normal saline with 2 mEq KCl/100 ml
Correct response: lactated Ringer's solution Explanation: Lactated Ringer's solution is recommended because it replaces the lost sodium and corrects the metabolic acidosis. If albumin is ordered, it's an adjunct therapy and not for primary fluid replacement. The stress from a burn injury affects the glucose metabolism. Dextrose shouldn't be given during the first 24 hours because it can put the client into pseudodiabetes. The client is hyperkalemic from the potassium shift from the intracellular spaces to the plasma, and additional potassium would be detrimental.
A laboring client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. Which medication would the nurse anticipate for these symptoms? terbutaline oxytocin magnesium sulfate calcium gluconate
Correct response: magnesium sulfate Explanation: Magnesium sulfate is the drug of choice to treat hypertension of pregnancy because it reduces edema by causing a shift from the extracellular spaces into the intestines. It also depresses the central nervous system, which decreases the incidence of seizures. Terbutaline is a smooth muscle relaxant used to relax the uterus. Oxytocin is the synthetic form of the pituitary hormone used to stimulate uterine contractions. Calcium gluconate is the antagonist for magnesium toxicity.
A client is receiving chlordiazepoxide as needed for signs and symptoms of alcohol withdrawal. The nurse assesses the client and determines the need for medication when the client displays: A. mild tremors, hypertension, and tachycardia. B. bradycardia, hyperthermia, and sedation. C. hypotension, decreased reflexes, and drowsiness. D. hypothermia, mild tremors, and slurred speech.
Correct response: mild tremors, hypertension, and tachycardia. Explanation: Chlordiazepoxide is given during alcohol withdrawal. Symptoms that indicate a need for this drug include tremors, hypertension, tachycardia, and elevated body temperature. Bradycardia, sedation, hypotension, decreased reflexes, hypothermia, and slurred speech aren't symptoms of alcohol withdrawal.
A client has been taking intravenous furosemide for congestive heart failure. The client is ordered to start intravenous gentamicin. What intervention is the priority for the nurse? monitor serum BUN and creatinine levels monitor serum furosemide level assess the I.V. site for phlebitis assess urine hourly output
Correct response: monitor serum BUN and creatinine levels Explanation: Concurrent furosemide and gentamicin (aminoglycoside pharm class) administration have a potential to increase both drugs' toxicity. This increases the risk of ototoxicity (hearing & balance) and nephrotoxicity. The nurse should monitor renal labs including BUN and creatinine, tinnitus, and balance/gait. Urine output should be monitored, however, the BUN and creatinine will be impacted before there is a change in urine output. The I.V. site should be assessed regularly as part of routine nursing care, not as a priority for the administration of these drugs. A serum furosemide is not a routine lab during the administration of these medications.
The client has second- and third-degree burns. The family asks if there is anything that can be given to the client for pain. Which analgesic would the nurse anticipate to manage the client's pain? A. heparin administered by IV B. meperidine administered by IM C. codeine administered by PO D. morphine administered by IV
Correct response: morphine administered by IV Explanation: The best and most effective medication for second- and third-degree burns would be IV morphine. IM medications may not be absorbed, and codeine may not provide sufficient analgesia.
A client reports pain one day after a colostomy. The nurse administers 4 milligrams morphine I.V., and reassesses the client 30 minutes later. The following is noted: Respiratory rate at 8 breaths/min. Nasal cannula on floor. Arterial blood gas (ABG) results are: pH, 7.23; PaO2, 58 mm Hg; PaCO2, 61 mm Hg; HCO3 24 mEq/l. Which factors most likely contribute to this client's ABG results? A. colostomy, pain, and morphine B. Morphine, the nasal cannula on the floor, and the colostomy C. morphine, respiratory rate of 8 breaths/min, and the nasal cannula on the floor D. pain, respiratory rate of 8 breaths/min, and the nasal cannula on the floor
Correct response: morphine, respiratory rate of 8 breaths/min, and the nasal cannula on the floor Explanation: This client has respiratory acidosis. Opioids can suppress respirations, causing retention of carbon dioxide. A PaO2 of 58 mm Hg indicates hypoxemia caused by the removal of the client's supplementary oxygen and decreased respiratory rate. Pain increases the rate of respirations, which causes a decrease in PaCO2. Colostomy drainage doesn't start until 2 to 3 days postoperatively, and this drainage would contribute to metabolic alkalosis.
An outpatient client who has been receiving haloperidol for two days develops muscular rigidity, altered consciousness, a temperature of 103° F (39.4° C), and trouble breathing on day 3. The nurse interprets these findings as indicating which complication? neuroleptic malignant syndrome tardive dyskinesia extrapyramidal adverse effects drug-induced parkinsonism
Correct response: neuroleptic malignant syndrome Explanation: The client is exhibiting hallmark signs and symptoms of life-threatening neuroleptic malignant syndrome induced by the haloperidol. Tardive dyskinesia usually occurs later in treatment, typically months to years later. Extrapyramidal adverse effects (dystonia, akathisia) and drug-induced parkinsonism, although common, are not life threatening.
A client with major depressive disorder is receiving phenelzine. The nurse intervenes when the client orders which food for lunch? pepperoni pizza yogurt with fruit Salisbury steak green beans
Correct response: pepperoni pizza Explanation: Clients taking phenelzine, a monoamine oxidase inhibitor, cannot take foods with high tyramine content. Pepperoni is a sausage with a high tyramine content. Yogurt with fruit, Salisbury steak, and green beans have little or no tyramine.
A client has been receiving total parenteral nutrition (TPN) for the last 5 days. Before discontinuing the infusion, the infusion rate is slowed. What complication of TPN infusion should the nurse assess the client for as the infusion is discontinued? essential fatty acid deficiency dehydration rebound hypoglycemia malnutrition
Correct response: rebound hypoglycemia Explanation: When dextrose is abruptly discontinued, rebound hypoglycemia can occur. The nurse should assess the client for symptoms of hypoglycemia. Essential fatty acid deficiency is very unlikely to occur because some of these fatty acids are stored. Preventing dehydration or malnutrition is not the reason for tapering the infusion rate; the client's hydration and nutritional status and ability to maintain adequate intake must be established before TPN is discontinued.
Which is most critical for the nurse to communicate to the health care provider (HCP) prior to placing an epidural analgesia catheter? The client: consumed 240 mL of beef broth 4 hours prior. has had an indwelling urinary catheter in place for 2 days. received enoxaparin 40 mg subcutaneously 1 hour ago. has an albumin level of 3.5 g/dL.
Correct response: received enoxaparin 40 mg subcutaneously 1 hour ago. Explanation: Clients receiving anticoagulation are at high risk for an epidermal hematoma (when blood accumulates between the skull and the dura mater). If the client is taking any anticoagulants, this should be immediately relayed to the HCP scheduled to perform the procedure. Clear liquids may be limited 2 hours prior to the procedure, but this varies by HCP and institutional guidelines. The albumen level is on the lower end of normal and is not a concern. The indwelling urinary catheter is not a concern at this time.
A client with acute pulmonary edema has been taking an angiotensin-converting enzyme (ACE) inhibitor. The nurse explains that this medication has been ordered to promote diuresis. increase cardiac output. decrease contractility. reduce blood pressure.
Correct response: reduce blood pressure. Explanation: ACE inhibitors are given to reduce blood pressure by inhibiting aldosterone production, which in turn decreases sodium and water reabsorption. ACE inhibitors also reduce production of angiotensin II, a potent vasoconstrictor. Diuretics are given to increase urine production. Vasodilators increase cardiac output. Negative inotropic agents decrease contractility.
One hour after receiving pyridostigmine bromide for myasthenia gravis, a client reports difficulty swallowing and excessive respiratory secretions. What medication would the nurse anticipate to reverse the effects of pyridostigmine bromide? additional pyridostigmine bromide atropine edrophonium acyclovir
Correct response: reduce blood pressure. Explanation: ACE inhibitors are given to reduce blood pressure by inhibiting aldosterone production, which in turn decreases sodium and water reabsorption. ACE inhibitors also reduce production of angiotensin II, a potent vasoconstrictor. Diuretics are given to increase urine production. Vasodilators increase cardiac output. Negative inotropic agents decrease contractility.
A client who is receiving acetaminophen for osteoarthritis reports continuing pain. The healthcare provider prescribes celecoxib. What important information regarding this medication, should the nurse share with this client? A. report black and tarry stools to the health care provider B. use a stool softener or fiber laxative daily to prevent constipation C. if you miss a dose, take a double dose the next day D. don't take the medication with dairy products
Correct response: report black and tarry stools to the health care provider Explanation: Black and tarry stools are a sign of gastrointestinal (GI) bleeding, and may necessitate a medication change. Dairy products can help reduce GI irritation. The celecoxib dose should never be doubled. Constipation isn't an adverse effect of this medication.
A nurse is caring for a client receiving lidocaine I.V. Which factor is most relevant to administration of this medication? A. decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter B. increase in systemic blood pressure C. runs of ventricular tachycardia on a cardiac monitor D. increase in intracranial pressure (ICP)
Correct response: runs of ventricular tachycardia on a cardiac monitor Explanation: Physicians sometimes use lidocaine drips to treat clients whose arrhythmias haven't been controlled with oral medication and whose runs of ventricular tachycardia are visible on the cardiac monitor. SaO2, blood pressure, and ICP are important factors but aren't as significant as ventricular tachycardia in this situation.
A client with a positive Mantoux test result is taking isoniazid (INH) and rifampin (RIF) for treatment of tuberculosis. In the nursing assessment, the nurse should assess specifically for which finding during the clinic visit? sclera peripheral edema dyspnea pruritus
Correct response: sclera Explanation: Clients taking isoniazid may show signs of hepatic stress. The nurse should assess for signs of liver dysfunction. Although if jaundice is present a client would potentially have pruritus, the early sign is sclera yellowing.
A client comes to the emergency department with severe back pain. The client reports taking several pain pills at home but cannot remember how many and provides the nurse with an empty bottle of acetaminophen with codeine. Which laboratory value should the nurse address? A. serum aminotransferase level (AST) of 256 u/L and international normalized ratio (INR) of 3.0 B. blood urea nitrogen (BUN) of 22 mg/dL and serum creatinine of 1.35 mg/dL C. creatine phosphokinase (CPK) of 21 U/L D. sodium (Na+) of 145 mEq/L and potassium (K+) of 4.5 mEq/L
Correct response: serum aminotransferase level (AST) of 256 u/L and international normalized ratio (INR) of 3.0 Explanation: Hepatic necrosis is the most serious toxic effect of an acute overdose of acetaminophen. The nurse should monitor the liver enzymes and INR level. Renal failure is not a consideration since the lab values are within normal limits. Total CPK would not need to be monitored; if the level is high, it usually means there has been injury or stress to muscle tissue, the heart, or the brain. The CPK level is within normal limits. Both the Na+ and K+ levels are also within normal limits.
When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which laboratory value? serum sodium serum potassium serum creatinine serum calcium
Correct response: serum creatinine Explanation: It is essential to monitor serum creatinine in the client receiving an aminoglycoside antibiotic because of the potential of this type of drug to cause acute tubular necrosis. Aminoglycoside antibiotics do not affect serum sodium, potassium, or calcium levels.
A nurse is teaching a client who has HIV about the adverse effects of saquinavir. What information is important to include? hypoglycemia thrombocytopenia leukocytosis hypolipidemia
Correct response: thrombocytopenia Explanation: Saquinavir is an antiretroviral-protease inhibitor used in combination with other antiretroviral medications to help manage HIV. Adverse effects include hyperglycemia, bone loss, hypersensitivity reaction, hyperlipidemia, thrombocytopenia, and leukopenia.
A client is taking vancomycin. The nurse should report which possible side effect to the health care provider? vertigo tinnitus muscle stiffness ataxia
Correct response: tinnitus Explanation: The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated with vancomycin.
The family of a client in rehabilitation following heroin withdrawal asks a nurse why the client is receiving naltrexone. What is the nurse's best response? to help reverse withdrawal symptoms to keep the client sedated during withdrawal to take the place of detoxification with methadone to decrease the client's memory of the withdrawal experience
Correct response: to help reverse withdrawal symptoms Explanation: Naltrexone is an opioid antagonist and helps the client stay drug free. Keeping the client sedated during withdrawal isn't the reason for giving this drug. The drug doesn't decrease the client's memory of the withdrawal experience, and isn't used in place of detoxification with methadone.
The nurse is preparing to administer vasopressin to a client who has undergone a hypophysectomy. What is the purpose of the medication? A. to treat growth failure B. to prevent syndrome of inappropriate antidiuretic hormone (SIADH) C. to reduce cerebral edema and lower intracranial pressure D. to replace antidiuretic hormone (ADH) normally secreted from the pituitary
Correct response: to replace antidiuretic hormone (ADH) normally secreted from the pituitary Explanation: After hypophysectomy, or removal of the pituitary gland, the body can't synthesize ADH; therefore, vasopressin is administered. Somatropin or growth hormone is used to treat growth failure. SIADH results from excessive ADH secretion. Vasopressin is not used to treat cerebral edema.
A primipara who is Rho(D) negative has just given birth to a Rh-positive baby. The nurse is developing a plan of care. How should Rho(D) immune globulin be administered? A. to the neonate within 3 days B. to the client within 3 days C. to the client at her first postpartum visit in 6 weeks D. to the neonate at the first well-baby visit
Correct response: to the client within 3 days Explanation: Administering Rho(D) immune globulin to the client within 72 hours of birth prevents antibodies from forming that can destroy fetal blood cells in the next pregnancy. Rho(D) immune globulin isn't given to the baby. The client should not wait 6 weeks to receive Rho(D) immune globulin as antibodies will already have formed.
Before starting treatment for leukemia, a client receives I.V. fluids and allopurinol. These interventions reduce the risk for disseminated intravascular coagulation (DIC). pancytopenia. tumor lysis syndrome. mucositis.
Correct response: tumor lysis syndrome. Explanation: During chemotherapy for leukemia, tumor lysis syndrome may occur as cell destruction releases intracellular components, resulting in hyperuricemia. Large fluid quantities and allopurinol therapy help reduce the amount of uric acid that results from tumor lysis syndrome but don't stop the cell lysis. Although DIC, pancytopenia, and mucositis are possible chemotherapy complications, they're not treated with I.V. fluids and allopurinol.
Before starting treatment for leukemia, a client receives I.V. fluids and allopurinol. These interventions reduce the risk for A. disseminated intravascular coagulation (DIC). B. pancytopenia. C. tumor lysis syndrome. D. mucositis.
Correct response: tumor lysis syndrome. Explanation: During chemotherapy for leukemia, tumor lysis syndrome may occur as cell destruction releases intracellular components, resulting in hyperuricemia. Large fluid quantities and allopurinol therapy help reduce the amount of uric acid that results from tumor lysis syndrome but don't stop the cell lysis. Although DIC, pancytopenia, and mucositis are possible chemotherapy complications, they're not treated with I.V. fluids and allopurinol.
A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, the physician connects a 10-ml syringe to the catheter and withdraws a sample of blood. The physician then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. The nurse should... A. place the client in a supine position and prepare to perform cardiopulmonary resuscitation. B. place the client in high-Fowler's position and administer supplemental oxygen. C. turn the client on the left side and place the bed in Trendelenburg's position. D. position the client in the shock position with legs elevated.
Correct response: turn the client on the left side and place the bed in Trendelenburg's position. Explanation: A nurse who suspects an air embolism should place the client on their left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.
Which clinical manifestations should the nurse expect to assess in a client diagnosed with an overdose of a cholinergic agent? Select all that apply. dry mucous membranes urinary incontinence central nervous system (CNS) depression seizures skin rash
Correct response: urinary incontinence central nervous system (CNS) depression seizures Explanation: An excess of cholinergic agents produces urinary and fecal incontinence, increased salivation, diarrhea, and diaphoresis. In a severe overdose, CNS depression, seizures and muscle fasciculations, bradycardia or tachycardia, weakness, and respiratory arrest due to respiratory muscle paralysis occur. Anticholinergics produce dry mucous membranes. Skin rash is not a sign of overdose with a cholinergic agent.
Which physical assessment data would alert the nurse to a possible mild toxic reaction in a client receiving lithium? vomiting and diarrhea hypotension seizures increased appetite
Correct response: vomiting and diarrhea Explanation: Vomiting and diarrhea are signs of mild to moderate lithium toxicity. Hypotension and seizures occur with moderate to severe toxic reactions. Anorexia occurs with mild toxic reactions.
Which physical assessment data would alert the nurse to a possible mild toxic reaction in a client receiving lithium? A. vomiting and diarrhea B. hypotension C. seizures S. increased appetite
Correct response: vomiting and diarrhea Explanation: Vomiting and diarrhea are signs of mild to moderate lithium toxicity. Hypotension and seizures occur with moderate to severe toxic reactions. Anorexia occurs with mild toxic reactions.
The nurse is preparing a teaching plan about increased exercise for a female client who is receiving long-term corticosteroid therapy. What type of exercise is most appropriate for this client? floor exercises stretching running walking
Correct response: walking Explanation: The best exercise for females who are on long-term corticosteroid therapy is a low-impact, weightbearing exercise such as walking or weight lifting. Floor exercises do not provide for the weightbearing. Stretching is appropriate but does not offer sufficient weightbearing. Running provides for weightbearing but is hard on the joints and may cause bleeding.
The nurse is caring for a client with an I.V. line. During care of the I.V. line, the nurse would be required to wear protective gloves in which situations? Select all that apply. when inserting the I.V. When discontinuing the I.V. When changing the I.V. site When spiking a new I.V. bag When priming the I.V. tubing
Correct response: when inserting the I.V. When discontinuing the I.V. When changing the I.V. site Explanation: The nurse should wear protective gloves when inserting the I.V., when discontinuing the I.V., and when changing the I.V. site due to the risk of exposure to blood and bodily fluids. The nurse would not be required to wear protective gloves while spiking or hanging a new bag of solution.
When a nurse tries to administer medication, the client refuses it, saying, "I don't have to take those pills if I don't want to." What intervention by the nurse would have the highest priority? A. insisting that the client take the medication because it is specifically ordered for the client B. reporting the client's comments to the physician and the treatment team C. explaining the consequences of not taking the medication, such as a negative outcome D. exploring how the client's feelings affect the decision to refuse medication
D. exploring how the client's feelings affect the decision to refuse medication Explanation: By helping the client explore their feelings about the change in health status, the nurse can determine how these feelings affect the decision to refuse medication. Then the nurse can help the client develop new ways to satisfy self-care, esteem, and other needs and, ultimately, participate fully in the therapeutic regimen. Insisting that the client take the medication, reporting the client's comments to the physician, and explaining the consequences of not taking the medication are inappropriate because these actions do not explore the client's feelings.
grams to kg conversion
Divide by 1000 1,000 g = 1 kg;
When can you use gluteal administration of IM injections in children?
Gluteal administration of IM injections is rare in children, you may use the ventrogluteal site in certain circumstances—for example, when a child's condition prevents administration in other sites. If you must use the ventrogluteal site, be sure to correctly identify anatomic landmarks before administration to prevent injury.
Tetany & tremors are related to what electrolyte imbalance?
Hypocalcemia
What is a loading dose of a medication mean?
In pharmacokinetics, a loading dose is an initial higher dose of a drug that may be given at the beginning of a course of treatment before dropping down to a lower maintenance dose. A loading dose is most useful for drugs that are eliminated from the body relatively slowly, i.e. have a long systemic half-life.
Creatinine lab values
Men 0.74-1.35 Women 0.59-1.04
What drugs cause ototoxicity?
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), including aspirin, ibuprofen, and naproxen. Certain antibiotics, including aminoglycosides. Certain cancer medications.
why might IM injections increase elevated serum enzyme levels (such as creatine kinase)?
Note that IM injections may damage local muscle cells, causing elevated serum enzyme levels (such as creatine kinase) that may be confused with the elevated enzyme levels resulting from damage to cardiac muscle from, for instance, a myocardial infarction. If the measurement of enzyme levels is important, suggest that the practitioner switch to medication administration via the IV route, if appropriate, and adjust dosages accordingly.
meperidine hydrochloride
Schedule II Also called Demerol. A drug used to treat moderate to severe pain. It binds to opioid receptors in the central nervous system. Meperidine hydrochloride is a type of analgesic agent and a type of opioid.
What is the use of the drug tamoxifen citrate?
Tamoxifen is an antiestrogen drug that has been found to be effective against metastatic breast cancer and to improve the survival rate. The drug causes hot flashes as an adverse effect.
Preferred IM injection site for Children (ages 3 to 18 years)
The deltoid muscle (shown above) is the preferred site for IM injection in children ages 3 to 18. The needle size for deltoid injections can range from 22G to 25G and from ⅝" to 1" (1.6 to 3.2 cm). The vastus lateralis muscle of the anterolateral aspect of the thigh (shown above) may also be used for IM injection in children ages 3 to 18.414243 The needle should be 22G to 25G and from 1" to 1¼" (2.5 to 3.18 cm).
What is the maximum injection volume for the ventrogluteal?
The maximum injection volume for this area is 5 mL. (same as the vastus lateralist)
What is the maximum injection volume for the vastus lateralist?
The maximum injection volume for this area is 5 mL. (same as the ventrogluteal)
Syndrome of inappropriate antidiuretic hormone secretion Also called: SIADH
The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a disorder of impaired water excretion caused by the inability to suppress the secretion of antidiuretic hormone (ADH causes the body to retain water. Causes hyponatermia Early symptoms may be mild and include cramping, nausea, and vomiting. In severe cases, SIADH can cause confusion, seizures, and coma.
isoniazid
Ther. Class.antituberculars Indication: First-line therapy of active tuberculosis, in combination with other agents. Prevention of tuberculosis in patients exposed to active disease (alone). Pt teaching: Advise patient to notify health care professional promptly if signs and symptoms of hepatitis (yellow eyes and skin, nausea, vomiting, anorexia, dark urine, unusual tiredness, or weakness) or peripheral neuritis (numbness, tingling, paresthesia) occur. Pyridoxine (B6) may be used concurrently to prevent neuropathy or to treat overdose -Avoid use of alcohol
rifampin (RIF)
Ther. Class.antituberculars Indications Active tuberculosis (with other agents). Elimination of meningococcal carriers. Inform patients taking rifampin that saliva, sputum, sweat, tears, urine, and feces may become red-orange to red-brown and that soft contact lenses may become permanently discolored. Patient/Family Teaching Advise patient to take medication once daily (unless biweekly regimens are used), as directed, and not to skip doses or double up on missed doses. Emphasize the importance of continuing therapy even after symptoms have subsided. Length of therapy for tuberculosis depends on regimen being used and underlying disease states. Patients on short-term prophylactic therapy should also be advised of the importance of compliance with therapy. Advise patient to notify health care professional promptly if signs and symptoms of hepatitis (yellow eyes and skin, nausea, vomiting, anorexia, unusual tiredness, weakness) or of thrombocytopenia (unusual bleeding or bruising) occur. Caution patient to avoid the use of alcohol during this therapy, because this may increase the risk of hepatotoxicity. Instruct patient to report the occurrence of flu-like symptoms (fever, chills, myalgia, headache) promptly. Rifampin may occasionally cause drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Inform patient that saliva, sputum, teeth, sweat, tears, urine, and feces may become red-orange to red-brown and that soft contact lenses may become permanently discolored. Advise patient that this medication has teratogenic properties and may decrease the effectiveness of oral contraceptives. Counsel females of reproductive potential to use a nonhormonal form of contraception throughout therapy. Emphasize the importance of regular follow-up exams to monitor progress and to check for side effects.
What gage & length of needle would you use for a pediatric patient?
Usually, the needle size ranges from 22G to 25G and from ⅝" to 1" (1.6 to 3.2 cm).
How does salt impact lithium?
While taking lithium, do not make sudden changes to your salt intake. A sudden decrease in sodium intake (a component of salt) may result in higher serum lithium levels, while a sudden increase in sodium might prompt your lithium levels to fall.
dystonia
abnormal muscle tone
Foods that contain tyramine
aged cheese, cured meats, picketed or fermented vegetables, fresh citrus, dried fruit, ripe bananas, rip avocados, smoked fish, some beers, and red wine
vasopressin
also called antidiuretic hormone (ADH) When ADH makes it to your kidneys, it signals them to conserve water and produce more concentrated urine Hormone It can treat diabetes insipidus. It is also used after stomach surgery or before stomach x-rays. In addition it can also increase blood pressure in patients with vasodilatory shock.
Normal BUN lab
around 6 to 24 mg/dL (2.1 to 8.5 mmol/L )
Monoamine Oxidase Inhibitors (MAOIs)
class of antidepressant drugs sometimes used for treating depression Examples: Phenelzine, selegiline, tranylcypromine, isocarboxazid Avoid foods high in tyramine content
anticholinergic side effects
dry mouth, constipation, nausea, vomiting, and urinary retention
Extravasation
escape of blood from the blood vessel into the tissue
muscle weakness & irregular pulse related to what electrolyte imbalance?
hypokalemia
headaches & poor tissue turgor is related to what electrolyte imbalance?
hyponatremia
purple glove syndrome
is a rare complication of intravenous phenytoin use that typically presents with pain, edema, and discoloration at the injection site that spreads to the distal limb.
cholinergic toxicity s/sx
may cause central depression mnemonic "SLUDGE syndrome" ( Salivation, Lacrimation, Urination, Defecation, Gastrointestinal distress and Emesis)
akathisia
restlessness
extrapyramidal side effects
reversible movement disorders induced by antipsychotic or neuroleptic medication ACUTE DYSTONIC REACTION: sudden onset sustained muscle contractions AKATHISIA: restlessness with inability to sit still drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces AKINISIA: loss of involuntary movement TARDIVE DYSKININIA NEUROLEPTIC MALIGNANT SYNDROME
Whats are the s/sx of an infiltrated IV site?
swelling, pain, hardness, pallor, and coolness of the skin at the site.
Z-track technique
technique used to administer medications intramuscularly that ensures that the medication does not leak back along the needle track and into the subcutaneous tissue, reducing pain and discomfort
Metronidazole (Flagyl)
treatmemt for trichomoniasis. dont take with alcol or for 24 after coompleting. can cause a metallic taste and cause urine to change a deep red-brown color.
IM sites
ventrogluteal, vastus lateralis, deltoid
