NCLEX practice Question
Which would be the respiratory rate in a 2-year-old child? 20 breaths/min 30 breaths/min 40 breaths/min 50 breaths/min
The normal range for the respiratory rate in a 2-year-old child (toddler) is between 25 and 32 breaths/min. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40 breaths/min. The normal respiratory rate in infants is 50 breaths/min.
The nurse would assess a client who underwent a paracentesis with 1500 mL removed for which complication? Dry mouth Tachycardia Hypertensive crisis Increased abdominal distention
tachycardia Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemia and compensatory tachycardia. Dry mouth may occur with dehydration, but it is not as vital or immediate as signs of shock. Dry mouth is a subjective symptom that cannot be measured objectively. The fluid shift can cause hypovolemia with resulting hypotension, not hypertension. A paracentesis decreases the degree of abdominal distention.
A client with a myocardial infarction is admitted to the cardiac intensive care unit. Which pain relief medication would the nurse expect to find on the plan of care for this client? morphine diazepam midazolam oxycodone
Morphine is the medication of choice for a myocardial infarction because it relieves pain quickly and reduces anxiety. It also decreases cardiac workload. Diazepam is a muscle relaxant that may be used for its sedative effect; it is not effective for the severe pain associated with a myocardial infarction. Midazolam is a hypnotic that may be used to reduce fear and restlessness; it is not effective for the severe pain associated with a myocardial infarction. Oxycodone is an orally administered analgesic; an analgesic that is administered via the intravenous, not the oral, route provides more immediate pain relief.
In which category of fluids would the nurse classify an intravenous solution of 0.45% sodium chloride? Isotonic Isomeric Hypotonic Hypertonic
Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure because their concentration is equivalent to that of body fluid. This relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.
Which assessment is necessary for the nurse to complete in a client with chronic kidney disease receiving loop diuretics? Hemoglobin levels Occurrence of nausea Presence of constipation Intake and output measurement
Intake and output measurement Diuretics are administered to increase urine output, so the measure of intake and output are very important to diuretic use. Hemoglobin levels are important to monitor in the use of erythropoietin in the chronic kidney disease client. Nausea and constipation are important to monitor with the administration of iron-containing vitamins and mineral supplements.
Which clinical finding indicates that a client taking digoxin may have developed digoxin toxicity? Constipation Decreased urination Cardiac dysrhythmias Metallic taste in the mouth
The development of cardiac dysrhythmias is often a sign of digoxin toxicity. Constipation is not a sign of toxicity; gastrointestinal signs and symptoms of toxicity include anorexia, nausea, vomiting, and diarrhea. Decreased urination is not a sign of toxicity. Digoxin does not cause a metallic taste in the mouth.
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. Which stage of labor would the nurse record? First Second Prodromal Transitional
first The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.
During a teaching session about insulin injections, a client asks the nurse, "Why can't I take the insulin in pills instead of taking shots?" How will the nurse respond? "Insulin cannot be manufactured in pill form." "Insulin is destroyed by gastric juices, rendering it ineffective." "Your health care provider decides the route of administration." "Your health care provider will prescribe pills when you are ready.
Insulin in tablet form is inactivated by gastric juices; insulin given by injection avoids exposure to digestive enzymes. Insulin is not given orally at this time because it is inactivated by digestive enzymes. The response, "Your health care provider will prescribe pills when you are ready," is incorrect information and provides false reassurance; the client currently is insulin dependent. The response, "Your health care provider decides the route of administration," does not answer the client's question; insulin is administered intravenously or subcutaneously, and the route depends on the client's needs.
Between which weeks of gestation would a client with type 1 diabetes expect to increase her insulin dosage? 10th and 12th weeks of gestation 18th and 22nd weeks of gestation 24th and 28th weeks of gestation 36th and 40th weeks of gestation
24th and 28th week At the end of the second trimester and the beginning of the third trimester, insulin needs increase because of an increase in maternal resistance to insulin. During the earlier part of pregnancy, fetal demands for maternal glucose may cause a tendency toward hypoglycemia. During the last weeks of pregnancy, maternal resistance to insulin decreases, and insulin needs decrease accordingly.
While receiving a blood transfusion, a client develops acute dyspnea, generalized urticaria, a heart rate of 128 beats/minute, and a blood pressure of 70/38 mm Hg. Which type of reaction would the nurse conclude that the client probably is experiencing? Panic Pyrogenic Hemolytic Anaphylactic
Anaphylactic reactions result from hypersensitivity to a product in the blood. Signs and symptoms are due to bronchospasm, systemic vasodilation, and compensatory tachycardia. The client may go into life-threatening shock without prompt treatment. Panic reactions (also known as panic attacks) involve high levels of anxiety and may be coupled with autonomic symptoms such as tachycardia. Bacterial pyrogens are present in contaminated blood and can cause a febrile transfusion reaction; signs include fever and chills. Hemolytic reaction results from the incompatibility of a recipient's antibodies with transfused red blood cells (RBCs); the reactions result from RBC hemolysis, agglutination, and capillary plugging.
A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication would the nurse conclude that the client probably is experiencing? Salicylate toxicity Allergic reaction Withdrawal symptoms Aspirin tolerance
Aspirin is a salicylate; excessive aspirin ingestion can influence the vestibulocochlear nerve (cranial nerve VIII), causing tinnitus and dizziness. The client is experiencing symptoms of toxicity, not an allergic response. Withdrawal symptoms occur when a medication is no longer being administered. Tolerance describes a condition in which additional medication is needed to achieve an effect; it is not associated with the development of new symptoms.
During a procedure, the client's heart rate drops to 38 beats/min. Which medication is indicated to treat bradycardia? Digoxin Lidocaine Amiodarone Atropine sulfate
Atropine blocks vagal stimulation of the sinoatrial (SA) node, resulting in an increased heart rate. Digoxin slows the heart rate; hence, it would not be indicated in this situation. Lidocaine decreases myocardial sensitivity and will not increase the heart rate. Amiodarone is an antidysrhythmic medication used for ventricular tachycardia; it will not stimulate the heart rate.
Which clinical finding of an 8-year-old child with a history of asthma requires immediate intervention? Barrel chest Audible wheezing Heart rate of 105 beats per minute Respiratory rate of 30 breaths per minute
Audible wheezing that is heard without a stethoscope is an indication that the airways are significantly compromised, and this requires immediate medical intervention. Barrel chest is a sign of chronic asthma. Repeated attacks result in a fixed hyperaerated thoracic cavity; this clinical finding does not require intervention. A heart rate of 105 beats per minute is expected in an 8-year-old child, as is a respiratory rate of 30 breaths per minute.
An older adult seems to make up stories to fill in for memory lapses. Which behavior is the client displaying? Lying Denying Fantasizing Confabulating
Confabulation is the filling in of memory gaps as a protective mechanism. Lying is false or dishonest behavior that is conscious and deliberate and is used in an attempt to deceive or mislead. Denying is a refusal to believe or accept reality and is used as a protective defense mechanism. Fantasizing is a more-or-less connected series of mental images, such as those that occur in daydreams, that usually involve some unfulfilled desire.
Which autoantigens are responsible for the development of Crohn disease? Crypt epithelial cells Thyroid cell surface Basement membranes of the lungs Basement membranes of the glomeruli
Crypt epithelial cells are considered the autoantigens responsible for Crohn disease. Thyroid cell surfaces are autoantigens responsible for Hashimoto thyroiditis. The pulmonary and glomerular basement membranes act as autoantigens responsible for Goodpasture syndrome.
A client with diabetes asks how exercise will affect insulin and dietary needs. Which effects of exercise would the nurse share? Increases the amount of insulin needed and increases the need for carbohydrates Increases the amount of insulin needed and decreases the need for carbohydrates Decreases the amount of insulin needed and increases the need for carbohydrates Decreases the amount of insulin needed and decreases the need for carbohydrates
Exercise increases the uptake of glucose by active muscle cells; carbohydrates are needed to supply energy for the increased metabolic rate associated with exercise. The need for insulin is decreased.
A client reports facial lesions that are surrounded by redness and cause itching. On assessment, the lesions are found to be thick with a honey-colored crust and surrounded by erythema. Which infection is suspected by the primary health care provider? Shingles Impetigo Folliculitis Verruca vulgaris
Impetigo is a primary bacterial infection most common on the face. This is clinically manifested as vesiculopustular lesions that develop as thick, honey-colored crust surrounded by erythema. Shingles or herpes zoster is a viral infection that usually occurs unilaterally on the trunk, face, and lumbosacral areas. Folliculitis is a bacterial infection seen most commonly on the scalp, beard, and extremities in men. Verruca vulgaris is a viral infection that is clinically manifested as a circumscribed, hypertrophic, flesh-colored papule limited to the epidermis.
The health care provider prescribes peak and trough levels after initiation of intravenous antibiotic therapy. The client asks why these blood tests are necessary. Which reason would the nurse provide? They determine if the dosage of the medication is adequate." "They detect if you are having an allergic reaction to the medication." "The tests permit blood culture specimens to be obtained when the medication is at its lowest level." "These allow comparison of your fever to changes in the antibiotic level."
Medication dose and frequency are adjusted according to peak and trough levels to enhance efficacy by maintaining therapeutic levels. Peak and trough levels reveal nothing about allergic reactions. Blood cultures are obtained when the client spikes a temperature; they are not related to peak and trough levels of an antibiotic. A sustained decrease in fever is the desired outcome, not a reduction just at peak serum levels of the medication.Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question.
Which is the primary reason an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium is prescribed for a client with a nasogastric (NG) tube set to low intermittent suction? Prevent constipation Prevent dehydration Prevent vomiting Prevent electrolyte imbalance
Prevent electrolyte imbalance When clients do not receive nutrients or fluids by mouth and have a loss of electrolytes through the removal of gastric secretions via an NG tube, electrolyte imbalance is a primary concern. Constipation is usually not a concern in this situation. Although dehydration is a possible effect of an NG tube that removes gastric secretions and fluid, electrolyte balance is still the priority. An NG tube set to low intermittent suction usually relieves nausea and vomiting.
A client is admitted to the emergency department with burns to the anterior trunk, entire right arm, and anterior left arm. The practitioner prescribes morphine sulfate for pain. The nurse expects to administer this medication by which route? Orally Intravenously Subcutaneously Intramuscularly
The intravenous route is the preferred route for medication for a client with impaired peripheral circulation. Oral medications usually are not given to burn clients because of the frequent occurrence of paralytic ileus; oral analgesics take too long to provide immediate relief from pain. Impaired peripheral circulation does not permit accurate prediction of the dose absorbed when it is administered subcutaneously. Impaired peripheral circulation does not permit accurate prediction of the dose absorbed when it is administered intramuscularly.
Which statement is true regarding varicoceles? Varicoceles are commonly seen in prepubertal children. Varicoceles result in a partial or complete venous occlusion. Varicoceles result in a red, warm, and edematous scrotum. Varicoceles cause an elongation of the veins of the spermatic cord.
Varicocele is characterized by a dilation and elongation of the veins of the spermatic cord that is presently superior to a testicle. This condition is rarely seen in prepubertal children. Testicular torsion results in partial or complete venous occlusion. In cases of severe torsion, the scrotum becomes red, warm, and edematous.
A health care provider prescribes a diuretic for a client with hypertension. Which mechanism of action explains how diuretics reduce blood pressure? facilitate vasodilation promote smooth muscle relaxation reduce blood volume block sympathetic nervous system
Diuretics decrease blood volume by blocking sodium reabsorption in the renal tubules, thus promoting fluid loss and reducing arterial pressure. Direct relaxation of arteriolar smooth muscle is accomplished by vasodilators, not diuretics. Vasodilators, not diuretics, act on vascular smooth muscle. Medications that act on the nervous system, not diuretics, inhibit sympathetic vasoconstriction.
Which life-threatening complication may occur in clients taking high-dose or long-term ibuprofen? anaphylaxis GI bleed cardiac dysrhythmia disulfiram reaction
Ibuprofen irritates the GI mucosa and can cause mucosal erosion while decreasing platelet activity, which can result in GI hemorrhage. Cardiac dysrhythmias and anaphylaxis are not typically associated with high-dose or long-term administration of ibuprofen. Disulfiram reactions are associated with alcohol intake, not ibuprofen.
The nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which new prescription will the nurse question? Oral psyllium Oral potassium supplement Intravenous normal saline Magnesium citrate
Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Intravenous normal saline is the intervention of choice to manage dehydration due to diarrhea. Magnesium citrate has a laxative effect and would worsen the client's dehydration.
Which factor may cause neck pain in a client? Headache Poor posture Low body weight Sedentary lifestyle
Poor posture may affect the nerves innervating the neck, thereby causing pain in the neck. Headache may be associated with neck pain, but it does not precipitate neck pain. Low body weight and sedentary lifestyle may cause osteoporosis.
Which medication is unsafe to administer as an intravenous (IV) bolus? Saline flush Potassium chloride Naloxone Adenosine
Potassium chloride given as an IV bolus can cause cardiac arrest. It must be diluted and infused slowly through an IV infusion pump. Saline flush, naloxone, and adenosine are appropriate to be given as an IV bolus undiluted.
Which color tag will be given by the triage nurse to a client assigned to class IV during a mass casualty situation? Red Black Green Yellow
black A client considered class IV during triage in a mass casualty situation will be given a black tag. The red tag is associated with class I, green tag with class III, and yellow tag with class II.
A health care provider prescribes losartan for a client. Which is an important nursing action? Assess the client for hypokalemia. Administer the medication with food. Monitor the client's blood pressure. Monitor serum glucose levels
Losartan is an aldosterone receptor blocking antihypertensive. A lowering of the client's blood pressure reflects a therapeutic response and should be monitored regularly. The client may be at risk for hyperkalemia, not hypokalemia. Losartan may be taken without regard to meals. Although it may be beneficial for clients with diabetes, it does not affect serum glucose levels.
A 26-year-old G1 P0 client at 29 weeks' gestation has gained 8 lb (3.6 kg) in 2 weeks; her blood pressure has increased from 128/74 Hg to 150/90 mm Hg; and she has developed 1+ proteinuria on urine dipstick. Which condition do these signs suggest? Mild preeclampsia Severe preeclampsia Chronic hypertension Gestational hypertension
Mild preeclampsia Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension.
A mother whose son has acute glomerulonephritis (AGN) is fearful that her other children may contract the disorder. Which would the nurse tell the mother about the origin of AGN? "The disorder is difficult to prevent because the cause is unknown." "It is a result of an autoimmune response after a streptococcal infection." "It is transmitted through a sex-linked chromosome that occurs only in males." "The disorder is caused by clot formation in the kidney tubules as a response to an infection."
The beta-hemolytic streptococcal immune complex becomes trapped in the glomerular capillary loop, resulting in acute poststreptococcal glomerulonephritis. The cause of AGN is known; prevention depends on treating individuals who contract streptococcal infections with antibiotics. AGN is not inherited; it is an acquired disease. Incidence in males outnumbers that in females by a 2:1 ratio. The precipitating streptococcal infection usually is a localized pharyngitis, and clots do not form in the renal tubules.
Which is the priority assessment for the client who has Guillain-Barré syndrome with rapidly ascending paralysis? Monitoring urinary output Assessing nutritional status Monitoring respiratory status Assessing communication needs
Monitor respiratory status The most serious complication of Guillain-Barré syndrome is respiratory failure caused by respiratory muscle paralysis. Urinary retention is common in Guillain-Barré, but monitoring urinary output is of lower priority than monitoring respiratory status. If ascending paralysis impairs the gag reflex, clients may require tube feedings or parenteral nutrition. Assessing nutritional status, however, is of lower priority than monitoring respiratory status. If ascending paralysis impairs cranial nerve functioning or if the client is intubated, verbal communication abilities are lost.
Which statement made by a client recently diagnosed with type 1 diabetes indicates that further education is necessary regarding the teaching plan? "I will need to have my eyes and vision examined once a year." "I will need to check my blood sugar at home to evaluate my response to my treatment plan." "I can improve metabolic and cardiac risk factors of this disease if I follow a healthy diet and exercise routine." "Once I get my glucose levels under control, there is a good chance that I will be able to switch from insulin to an oral medication."
Type 1 diabetes mellitus (DM) is an autoimmune disorder in which beta cells are destroyed. No insulin or very little insulin is produced. A person with type 1 DM will need lifelong insulin injections to control blood sugar. Early detection of changes in the eye permits treatment plan adjustments that can slow or halt progression of retinopathy. Blood glucose monitoring should be done at home to evaluate the treatment plan. Disease risk factors can be improved with a healthy diet and exercise routine.
A client is receiving clonidine for hypertension. Which side effect of clonidine will the nurse include when providing medication education? Xerostomia Diarrhea Euphoria Photosensitivity
Xerostomia (dry mouth) is one of the common side effects of this medication. The reaction usually diminishes over the first 2 to 4 weeks of therapy. This medication causes constipation, not diarrhea. This medication may cause depression, anxiety, fatigue, and drowsiness, not euphoria. Photosensitivity is not a side effect of this medication.
A client has had an adjustable gastric banding procedure to reduce weight. At a follow-up visit, the client reports episodes of abdominal pain and vomiting after eating. Which recommendation would the nurse make? Drink 8 ounces (240 mL) of fluid with meals. Chew food thoroughly before swallowing. Eat larger amounts of food every 2 hours. Ingest food that has a high caloric density.
chew food thoroughly before swallowing Chewing helps slow down the eating process and breaks down food into smaller pieces. Well-chewed food is less likely to cause esophageal distention, abdominal cramps, or vomiting. Fluid intake should be limited with meals. Eating three to six small meals high in protein and low in carbohydrates and fat is recommended. Nutrient-dense, not calorie-dense, foods should be ingested by the client with a gastric banding.
A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. Which mechanism of action would the nurse identify for this medication? Blocks the effects of acetylcholine Increases the production of dopamine Restores the dopamine levels in the brain Promotes the production of acetylcholine
restores dopamine levels Levodopa is a precursor of dopamine, a catecholamine neurotransmitter; it increases dopamine levels in the brain that are depleted in Parkinson disease. Blocking the effects of acetylcholine is accomplished by anticholinergic medications. Increasing the production of dopamine is ineffective because it is believed that the cells that produce dopamine have degenerated in Parkinson disease. Levodopa does not affect acetylcholine production.
Which sign related to rubeola (measles) should alert parents to seek medical help? Macular rashes Scaly skin patches Bald patches on the scalp Generalized vesicular skin lesions
Rubeola (measles) starts with a discrete maculopapular rash on the face and spreads downward, eventually becoming confluent. Scaly skin occurs with eczema or dermatitis. Bald patches occur with tinea capitis (ringworm). Vesicular skin lesions occur with varicella (chickenpox).
The client with chronic arterial insufficiency of the legs refuses the prescribed dose of aspirin (ASA). The client states, "My legs are not painful." Which action will the nurse take? Explain the reason for the medication and encourage the client to take it. Withhold the medication at this time and return to check with the client again in 30 minutes. Withhold the medication and tell the client to ask for it if the legs become uncomfortable. Request that the client take the medication and explain that it prevents the client from being uncomfortable in the next few hours.
Aspirin is given to the client to prevent platelet aggregation and possible deep vein thrombosis. The client needs information to make an educated decision. Aspirin is not prescribed to relieve pain. The client should receive information and support before making the decision to refuse the medication. Clients should never be pressured to take medication, especially when they do not have an understanding of the risks and benefits of the medication.
A client with stage III Hodgkin's disease is started on a multiple-drug regimen of doxorubicin, bleomycin, vinblastine, and dacarbazine. Why are so many drugs necessary? Using smaller doses of several drugs reduces the likelihood of serious side effects. Each drug destroys the cancer cell at a different time in the cell cycle. Several drugs are used to destroy cells that are not susceptible to radiation therapy. Because there are stages of Hodgkin's disease, if one drug is ineffective, another will work.
Cells are vulnerable to specific drugs through the stages of mitosis, and a combination bombards the malignant cells at various stages. The side effects of a drug are not ameliorated by a combination with others. Although the statement that several drugs are used to destroy cells that are not susceptible to radiation therapy is true, it is not the reason for using a combination of drugs. Although there is more than one stage of Hodgkin's disease, this is not the reason for using a combination of drugs.
A client is admitted to the emergency department after experiencing a seizure. Which action would the nurse take first? Ask the emergency provider for a prophylactic anticonvulsant. Obtain a history of seizure type and incidence. Ask the client to remove any dentures and eyeglasses. Observe the client for increased restlessness and agitation
Data collection is an essential first step for a client with a seizure disorder; it should always include a history of the seizures (e.g., type and incidence). Because different seizure medicines are used to control different seizure types, it is important to determine the type before treating. Although dentures and eyeglasses may be removed during a seizure, the client's normal routines should be respected. Increased restlessness may be evidence of the prodromal phase of a seizure in some individuals, but signs and symptoms vary so widely that the client's history should be obtained.
For which circumstance would the nurse use the Z-track technique to administer a medication? A large volume of medication needs to be administered. The medication is irritating to subcutaneous tissue and skin. A depot medication is prescribed. The medication is lipophilic.
Medication is irritating to subcutaneous tissue and skin The Z-track method seals the puncture at the intramuscular level, preventing seepage of irritating medication up the needle track and thereby avoiding injury to subcutaneous tissue and skin. The Z-track technique is unrelated to the volume of medication to be administered. The Z-track technique is not required for administration of depot medications. Whether or not a medication is lipophilic has no bearing on the need for using the Z-track technique.
Which action would the nurse take for a client who is having a tonic-clonic seizure? Elevating the head of the bed Restraining the client's arms and legs Placing a tongue blade in the client's mouth Taking measures to prevent injury
Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.
An unconscious adolescent with type 1 diabetes is brought to the emergency department. The blood glucose level is 742 mg/dL (41.2 mmol/L). Which finding would the nurse expect during the initial assessment? Pyrexia Hyperpnea Bradycardia Hypertension
Rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a characteristic compensatory mechanism for correcting metabolic acidosis. An increase in temperature (pyrexia) will occur if an infection is present; it is not a response to hyperglycemia. Tachycardia, not bradycardia, results from the hypovolemia of dehydration. Hypotension, not hypertension, may result from the decreased vascular volume associated with hyperglycemia.
The nurse prepares to administer extended-release metformin to an older adult who has asked that it be crushed because it is difficult to swallow. Which rationale will prompt the nurse to ask the provider for a different form of metformin? This medication has a wax matrix frame that is difficult to crush. The medication has an unpleasant taste, which most clients find intolerable if crushed. If crushed, this medication irritates mucosal tissue and can cause oral and esophageal ulcer formation. Extended-release formulations are designed to be released slowly and crushing the tablet will prevent this from occurring.
The slow-release formulary will be compromised, and the client will not receive the entire dose if it is chewed or crushed. The capsules are not difficult to crush. Irritation of the mucosal tissue is not the reason the medication should not be crushed; however, this medication should be given with meals to prevent gastrointestinal irritation. Although taste could be a factor, it is not the priority issue.
Paracentesis is prescribed for a client recently admitted to a medical unit. The nurse recalls that the procedure is performed for which reasons? Select all that apply. One, some, or all responses may be correct. Extract peritoneal fluid Improve respiratory status Decrease intrapleural fluid Increase intra-abdominal tension Obtain peritoneal fluid for culture
extract peritoneal fluid, improve respiratory status, and obtain peritoneal fluid for culture. When a client has ascites, a peritoneal tap (paracentesis) may be prescribed to remove fluid for diagnostic purposes and for relief of discomfort. The removal of intra-abdominal fluid relieves pressure against the diaphragm, which will improve the client's respiratory status. A culture of peritoneal fluid may provide information about the cause of the ascites. Closed-chest drainage, not paracentesis, removes fluid from the pleural space. Paracentesis is done to decrease, not increase, intraabdominal pressure.
