NU 270 Module 8

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

B. Seizures. Rationale: Bupropion is an antidepressant. Seizure activity is common with dosages greater than 450 mg/day. It does not cause significant orthostatic blood pressure changes. Bupropion frequently causes a drop in body weight. Insomnia is a side effect, but seizure activity is more dangerous to the client.

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

B. Tarry stools. Rationale: Glucocorticoids increase gastric secretion, which may result in the development of peptic ulcers and gastrointestinal bleeding. Corticosteroids increase blood glucose. Dry mouth and hypotension are not side effects of corticosteroid therapy.

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

B.15 minutes. Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, the time frame during which most transfusion reactions occur. This will enable the nurse to quickly detect a reaction and intervene quickly. Five minutes is too short; the nurse would not be present during the critical 15 minutes. Staying with the client for 45 or 60 minutes is unnecessary.

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

B. Tarry stools D. Bleeding from the gums. Rationale: Heparin is an anticoagulant, and the client who receives continuous IV heparin is at risk for bleeding. The nurse must be alert for signs of bleeding: bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood.

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

A.Document the normal value on the chart. Rationale: The normal therapeutic range for theophylline is 10 to 20 mcg/mL. A level above 20 mcg/mL is considered toxic. A value of 16 mcg/mL is within the therapeutic range.

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

D.That darkening of the urine is a harmless side effect. Rationale: Metronidazole can produce a variety of untoward effects, but they rarely require termination of treatment. Harmless darkening of the urine may occur, and the client should be forewarned of this effect. The nurse would not instruct the client to discontinue the medication. It is not necessary that the client see the physician. Increasing fluid intake is a good health measure but will not prevent this expected side effect.

A nurse plans to teach the signs of rejection to a client who just had a transplanted kidney. What sign of rejection should the nurse include?

Hypertension results from hypervolemia because of failure of the new kidney. Weight gain will occur because of fluid retention with failure of a transplanted kidney. Body temperature will exceed 100° F if a kidney is rejected. Urine output will be decreased or absent, depending on the degree of failure.

Pulmonary Embolism causes:

Pulmonary embolism occurs when a blood clot, gets wedged into an artery in the lungs. These blood clots most commonly come from the deep veins of the legs. This condition is known as deep vein thrombosis (DVT).

Pulmonary embolism common signs and symptoms include:

Shortness of breath. This symptom typically appears suddenly and always gets worse with exertion. Chest pain that feels like a heart attack. The pain gets worse with exertion but won't go away with rest. The cough may produce bloody or blood-streaked sputum. Leg pain or swelling, or both, usually in the calf. Clammy or discolored skin (cyanosis). Fever and excessive sweating.

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

B. "I should expect to have ringing in my ears." Rationale: Furosemide is a loop diuretic. Adverse effects of furosemide therapy include orthostatic hypotension and ototoxicity. Therefore the client should change positions slowly to help prevent lightheadedness. The client must also contact the physician if signs of ototoxicity, such as hearing loss or ringing in the ears, occur. Fluid intake should be maintained to prevent dehydration.

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

A.Fever D. Sore throat E. Mouth sores. Rationale: Drowsiness, headache, nausea, and vomiting are frequent side effects of carbamazepine. Adverse reactions include blood dyscrasias; fever, sore throat, mouth ulcerations, unusual bleeding or bruising, or joint pain may be indicative of a blood dyscrasia, and the physician should be notified.

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

A. Rash B. Chills D. Backache. Rationale: The nurse should instruct the client to report signs of a transfusion reaction, such as a backache, chills, itching, or rash, immediately. If a transfusion reaction occurs, the nurse would stop the transfusion immediately. Fatigue, tiredness, and nausea are not specifically related to a transfusion reaction.

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

C. The client's blood pressure has decreased. Rationale: Metoprolol (Lopressor, Toprol-XL) is a cardioselective beta-blocking agent used after myocardial infarction, as well as for hypertension and angina. Side effects include bradycardia and such symptoms of congestive heart failure as weight gain and increased edema.

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

D.To space the doses evenly around the clock. Rationale: The adult dosage of zidovudine is usually 200 mg every 8 hours or 300 mg every 12 hours. The client is instructed to space doses of the medication evenly around the clock. Food or milk does not affect the gastrointestinal absorption of the medication. The client is instructed to continue therapy for the full prescribed duration of treatment. The client is also instructed not to take any medication, including aspirin, without the physician's approval.

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

A.Hypotension B.Constipation D.Urine retention E. Respiratory depression. Rationale: Side effects of meperidine hydrochloride (Demerol) include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urine retention.

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

B. In the morning. Rationale: Fluoxetine hydrochloride (Prozac) is a selective serotonin reuptake inhibitor that elicits an antidepressant response. It is best administered in the early morning, and there is no need to coordinate the dose with a meal. (If the medication causes lightheadedness or dizziness, the healthcare provider may advise the client to take it at bedtime.) The other options are incorrect.

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

11

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

21

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

21.

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

42

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

A. Atropine sulfate. Rationale: The treatment for cholinergic crisis is atropine sulfate. Protamine sulfate is the antidote for heparin, and acetylcysteine is the antidote for acetaminophen (Tylenol). Pyridostigmine bromide is an anticholinesterase agent used in the treatment of myasthenia gravis to improve muscle strength. An overdose of this medication can cause cholinergic crisis.

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

A. Chills B.Headache C. Chest and back pain D.Nausea and vomiting. Rationale: Signs of an adverse reaction to fat emulsion include chest and back pain, chills, fever, dyspnea, cyanosis, diaphoresis, flushing, headache, nausea and vomiting, pressure over the eyes, vertigo, and thrombophlebitis at the infusion site.

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

A. This is a side effect of therapy. Rationale: One common side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, is a persistent dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the physician if the cough becomes troublesome to them. The cough is reversible with discontinuation of the therapy. The other options are incorrect interpretations of the client's complaint.

A client has chronic asthma. For which complication should the nurse monitor this client?

Atelectasis: as a result of narrowed airways, adequate ventilation of lung tissue is compromised and alveoli may collapse.

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

B. 1800. Rationale: The PN solution should be changed every 24 hours as a means of helping prevent infection. Infection is also prevented with the use of aseptic technique during bag and tubing changes. Most agencies recommend that tubing be changed every 24 hours along with the PN infusion bag. Specific agency policies should always be followed. The nurse should also use a filter when administering PN in accordance with hospital protocol. Therefore the remaining options are incorrect.

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

B. Nasal congestion. Rationale: Common side effects of baclofen include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesia of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Paradoxical central nervous system excitement and restlessness may occur, along with slurred speech, tremor, dry mouth, nocturia, and impotence. Photosensitivity is not a side effect of this medication.

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

D. For measurement of blood pressure and apical pulse. Rationale: Betaxolol is an antiglaucoma medication and a beta-adrenergic blocker. Hypotension (manifested as dizziness), nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are side effects of the medication. Nursing interventions include blood pressure monitoring to detect hypotension and assessment of the pulse for strength, weakness, irregularity, and bradycardia. Blood glucose testing is not a part of follow-up with this medication; neither are weighing and urinalysis.

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

A. Motor restlessness. Rationale: Akathisia —motor restlessness, or the desire to keep moving —may appear within 6 hours of administration of the first dose of haloperidol. It may be difficult to distinguish from psychotic agitation. Tardive dyskinesia is uncontrolled rhythmic movements of the mouth, face, and extremities, including lip smacking or puckering, puffing of the cheeks, uncontrolled chewing, and rapid or wormlike movements of the tongue. The physician should be notified if any of these symptoms occurs.

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

B. Vertigo. Rationale: Ringing in the ears and vertigo are two symptoms that may indicate dysfunction of the eighth cranial nerve. Ototoxicity, a common adverse effect of therapy with the aminoglycosides, may result in permanent hearing loss. If signs of ototoxicity occur, the nurse should hold the next dose of the medication and notify the physician. Nausea, vomiting, and hypotension are rare side effects of the medication.

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

The correct order is: 1. Stopping the infusion of blood 2. Hanging an IV bag of normal saline solution (NS) at a keep-vein-open (KVO) rate 3. Notifying the healthcare provider 4. Obtaining vital signs/oxygen saturation 5. Documenting the findings. Rationale: If a transfusion reaction is suspected, the transfusion is immediately stopped and NS infused, pending further physician prescriptions. Next, the healthcare provider should be notified. Ensuring patent IV access also helps maintain the client's intravascular volume. NS is the solution of choice, rather than solutions containing dextrose, because red blood cells do not clump with NS. Vital signs and oxygen saturation are monitored closely. Finally, the nurse documents the findings and the client's response to the interventions.

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

B. Prevent postpartum bleeding. Rationale: Methylergonovine (Methergine), an ergot alkaloid /oxytocic agent, is used to prevent or control postpartum hemorrhage by inducing uterine contraction and enhancing myometrial tone. The immediate dose is usually administered intramuscularly, and then, if needed, the drug is given again by mouth. Methylergonovine increases the strength and frequency of contractions and may increase blood pressure. One priority before the administration of methylergonovine is assessment of the client's blood pressure. There is no relationship between the action of this medication and lochial drainage.

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

A. Call the healthcare provider. Rationale: If the client has a temperature of 100.0° F or higher, the unit of blood should not be hung until the physician has been notified and had the opportunity to give further prescriptions. It is likely that the healthcare provider will prescribe the blood to be administered despite the temperature, but it is not within the nurse's scope of practice to make that determination. Therefore the other options are incorrect. Additionally, medications are not administered to the client without a prescription.

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

A. Phentolamine. Rationale: The antidote to treat phenelzine-induced hypertensive crisis is phentolamine; a dose of 5 to 10 mg is usually injected intravenously. Hypertensive crisis may manifest as hypertension, frontally radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia or bradycardia and constricting chest pain may also be present.

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

A. Remove the IV. Rationale: Blanching, coolness, and edema of the IV site are all signs of infiltration. Because infiltration may result in damage to the surrounding tissue, the nurse must first remove the IV cannula to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein, because blood return may be present even if the cannula is only partially in the vein. Compresses may be used, but the compress (warm or cool) depends on the type of solution infusing and physician preference. The nurse should measure the area of infiltration after the IV has been removed so that further tissue damage is prevented.

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

B. Draw the regular insulin into the syringe first. Rationale: Before different types of insulin are mixed, the bottle should be rotated for at least one minute between the hands. This resuspends the insulin and helps warm the medication. The bottles should not be shaken; shaking causes the formation of bubbles, which may trap particles of insulin and alter the dosage of the medication. Insulin may be maintained at room temperature. A 25- to 28-gauge 5/8-inch needle should be used for subcutaneous injection of insulin. Bottles of insulin intended for future use should be stored in the refrigerator. Regular insulin is drawn up before NPH insulin to ensure that there is no contamination of the rapid-acting insulin by the intermediate-acting insulin. It is not necessary to remove air from the insulin bottle.

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

B. Drawing up the medication and discarding the unused portion. Rationale: Epoetin alfa is dispensed in a 1-mL vial for subcutaneous or IV injection. The vial should not be shaken, because epoetin alfa is a protein that can be denatured with agitation. The nurse should use only one dose per single-dose vial and discard the unused portion. Epoetin alfa is not to be mixed with other medications. The medication should be stored at 2° to 8 °C (35° to 46° F) and should not be frozen.

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

B. Jaundice. Rationale: Acetazolamide is a carbonic anhydrase inhibitor used in the treatment of glaucoma to reduce the rate of aqueous humor formation and to lower intraocular pressure. Adverse effects include nephrotoxicity, hepatotoxicity, and bone marrow depression. Jaundice is a sign of hepatotoxicity. Tinnitus is not related to this medication. Pupillary constriction in response to light is a normal response. Diminished peripheral vision would signal a complication of glaucoma.

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

B. Lung sounds. Rationale: Bleomycin sulfate, an antineoplastic medication, can cause interstitial pneumonitis that may progress to pulmonary fibrosis. Pulmonary function parameters, along with hematologic, hepatic, and renal function tests, must be monitored. The nurse should monitor lung sounds for dyspnea and wheezes, indicative of pulmonary toxicity. The medication must be discontinued immediately if pulmonary toxicity occurs.

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

B. Maintain a high-fiber diet. Rationale: Codeine sulfate can cause constipation. The client is instructed to increase fluid intake and maintain a high-fiber diet to help prevent constipation. The other options are incorrect because they do not address the side effects associated with the use of this medication. Although lightheadedness may occur with the use of this medication, all exercise is not avoided; in fact, the client should ambulate frequently.

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

B. Should be administered as prescribed. Rationale: Hypokalemia can make the client more susceptible to digoxin toxicity, so the nurse monitors the client's potassium level. The normal reference range of potassium for an adult is 3.5 to 5.1 mEq/L. If the potassium level is low, the dose is withheld and the physician is notified. In this situation, the dose should be administered as prescribed, because the potassium level is within the normal range.

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

B. Sudden drop in fetal heart rate. Rationale: Magnesium toxicity may result from magnesium sulfate therapy. Signs of magnesium sulfate toxicity, related to the central nervous system-depressant effects of the medication, include respiratory depression, loss of deep tendon reflexes, sudden drop in fetal or maternal heart rate, and decreased blood pressure. The therapeutic serum range for magnesium is 4 to 7 mEq/L. Proteinuria of 3+ is likely to be noted in a client with preeclampsia.

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

C. Shutting off the IV infusion. Rationale: The client's symptoms are indicative of speed shock, which results from the rapid infusion of drugs or a bolus infusion. In this case, the nurse would note that 400 mL has infused over 60 minutes. The first action on the part of the nurse is shutting off the IV infusion. Other actions may follow in rapid sequence: The nurse may elevate the head of the bed to aid the client's breathing and then immediately notify the healthcare provider. Slowing the infusion rate is inappropriate because the client will continue to receive fluid. The IV does not need to be removed. It may be needed to manage the complication.

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

D.Take a deep breath and hold it. Rationale: The nurse must ask the client to take a deep breath and hold it. This effectively achieves the Valsalva maneuver during tubing changes, which helps prevent air embolism. If the line is on the left, it may be helpful to have the client turn the head to the right and vice versa. This allows more room for the nurse to work. However, it is not the most essential action. The other options are incorrect.

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

D.To increase fluid intake to 2000 mL to 3000 mL/day. Rationale: Hemorrhagic cystitis is a toxic effect of cyclophosphamide. The client must be instructed to drink copious amounts of fluid during administration of this medication. The client should also monitor her urine for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia may also result from the use of the medication; therefore the client would not be encouraged to increase potassium intake (i.e., bananas and orange juice). The client also would not be instructed to alter her sodium intake.

"Penicillin G benzathine (Bicillin), 300,000 units/mL." How many milliliters of medication does the nurse prepares to ensure administration of the correct dose? (Round your answer to the nearest tenth.)

1

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

1

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

2

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

A.Platelet count. Rationale: Baseline assessment includes renal and liver function parameters. Risperidone is used with caution — often at a reduced dosage — in clients with renal or hepatic impairment, clients with underlying cardiovascular disorders, and in older or debilitated clients. The laboratory tests identified in the other options are not necessary.

What is Azotemia?

Abnormally high levels of nitrogen-containing compounds (such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds) in the blood. It is largely related to insufficient or dysfunctional filtering of blood by the kidney. It can lead to uremia and acute kidney injury (kidney failure) if not controlled.

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

B."I think you need to come in for blood work today, because this may be a side effect of your medicine." Rationale: Agranulocytosis, an adverse effect of antipsychotic medications, is characterized by a sore throat with mouth sores, fever, and malaise. Any client taking such a medication who complains of flulike symptoms should be evaluated carefully. For this reason, the psychiatrist usually prescribes periodic blood tests while a client is taking antipsychotic medications. The incorrect options ignore the client's complaints.

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

B.Hemoglobin. Rationale: Folic acid, necessary for red blood cell production, is classified as a vitamin and as an antianemic agent. Both hematocrit and hemoglobin are appropriate parameters by which to assess the blood count. The nurse can gauge the effectiveness of therapy by monitoring the results of periodic complete blood counts, in particular the hematocrit.

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

C. "When was your last drink of alcohol?" D. "Do you have a history of thyroid problems?" Rationale: Disulfiram (Antabuse) is used as an adjunct treatment for selected clients with alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important question is when the client had his last drink of alcohol. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in cases of severe heart disease, psychosis, or hypersensitivity to the medication.

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

C. Diphenhydramine (Benadryl). Rationale: An urticarial reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine, such as diphenhydramine. Acetaminophen and acetylsalicylic acid are analgesics; ibuprofen is a nonsteroidal antiinflammatory medication.

A client arrives at a health clinic reporting hematuria, frequency, urgency, and pain on urination. What does the nurse suspect is the cause of these signs and symptoms?

Cystitis (sis-TIE-tis) is the medical term for inflammation of the bladder. Most of the time, the inflammation is caused by a bacterial infection, and it's called a urinary tract infection (UTI). A bladder infection can be painful and annoying, and it can become a serious health problem if the infection spreads to your kidneys.

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

D. "Do you have any ringing in the ears?" Rationale: Mild intoxication with acetylsalicylic acid, called salicylism, is common when the daily dose is more than 4 g. Tinnitus (ringing in the ears) is the effect most frequently noted with intoxication. Hyperventilation may also occur, because salicylate stimulates the respiratory center. The client may have a fever, because salicylate interferes with oxygen consumption and heat production.

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

D. A client whose PN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating. Rationale: The nurse should assess the client complaining of weakness, headache, and sweating first, because these are signs of hypoglycemia, which could be caused by the decrease in the PN rate. The client who has been receiving PN at a rate of 50 mL/hr for the last 24 hours should be assessed but does not need to be seen first. The client who complains of frequent trips to the bathroom should be assessed for hyperglycemia, one of the side effects of PN, but should not take precedence over the client showing signs of hypoglycemia. A client with an increased temperature should be monitored closely but does not take precedence over the client exhibiting signs of hypoglycemia.

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

D. A white blood cell (WBC) count of 2000 cells/mm3. Rationale: The normal WBC count is 4500 to 11,000 cells/mm3. When the WBC count drops, neutropenic precautions — including protective isolation to protect the client from infection — must be implemented. Bleeding precautions must be initiated when the platelet count drops. With bleeding precautions, traumatic procedures such as injections and rectal temperatures are avoided. The normal platelet count is 150,000 to 450,000 cells/mm3. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/dL.

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

D. Respiratory rate of 10 breaths/min. Rationale: Before an opioid is administered, respiratory rate, blood pressure, and pulse rate should be measured. The medication should be withheld and the physician notified if the respiratory rate is 12 breaths/min or slower, if the blood pressure is significantly below the pretreatment value, or if the pulse rate is significantly above or below the pretreatment value. A urine output of 30 mL/hr is normal. A temperature of 97.6° F is below normal, but it is not necessary to notify the physician of this reading.

A nurse is caring for a client who had a kidney transplant. Which test is most important for determining whether a client's newly transplanted kidney is working effectively?

Serum creatinine, a test of renal function, measures the kidneys' ability to excrete metabolic wastes; creatinine, a nitrogenous product of protein breakdown, is elevated in renal insufficiency.

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

c. On an empty stomach. Rationale: Oral erythromycin should be taken on an empty stomach with a full glass of water. Some preparations may be administered with food if gastrointestinal upset occurs, but it is best to administer the drug on an empty stomach.

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

D. Reduce the risk of deep vein thrombosis. Rationale: Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis and thromboembolism in selected at-risk clients. It is not used to prevent pain, relieve back spasms, or increase the energy level.

The nurse is caring for a client that has a lesion in the right upper lobe. A diagnosis of tuberculosis (TB) has been made. What are the clinical manifestations of tuberculosis?

People exposed to the client need screening, and it is appropriate to start with a skin test; those with positive reactions should be tested further. Making a list of all the people the client has had contact with over the past year is not necessary and is impractical. Only close family, friends and employees in proximity to the client need be notified and screened.

What nursing action will limit hypoxia when suctioning a client's airway?

The negative pressure from suctioning removes oxygen as well as secretions; suction should be applied only after the catheter is inserted and is being withdrawn. Suctioning should be limited to only 10 seconds.

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

A.Removes the IV catheter. Rationale: Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may be indicated by client discomfort at the site or by redness, warmth, and swelling in the area of the catheter. The IV catheter should be removed and a new IV line inserted at a different site. Slowing the rate of infusion and checking for loose catheter connections are not correct responses. The healthcare provider would be notified if phlebitis were to occur, but this is not the initial action.

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

B. "I won't take any over-the-counter medications except aspirin." Rationale: No over-the-counter medications of any kind should be ingested by a client taking an anticoagulant. This is especially true of aspirin and aspirin-containing products (because of the potential for bleeding). The other options are correct statements. Strenuous games (e.g., contact sports) that may result in bruising and skin breakdown should be avoided. Electric shavers are less irritating to the skin than razors and less likely to cause skin breakdown. Medication alert tags are recommended in case of emergency. The client should also be taught to carry an identification card listing all medications currently being taken.A nurse is preparing a plan of care for a client with a diagnosis of cancer who is receiving morphine sulfate for pain. Which of the following actions does the nurse identify as a priority in the plan of care for this client? D. Monitoring the client's respiratory rate. Rationale: Morphine sulfate suppresses respiration, and monitoring respirations is a priority nursing action. Although the other options may be a component of the plan of care for this client, monitoring the client's respiratory rate is the priority nursing action.

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

B. To rise slowly from a lying to a sitting position. Rationale: Quinapril hydrochloride is an angiotensin-converting enzyme (ACE) inhibitor used in the treatment of hypertension. The client should be instructed to rise slowly from a lying to a sitting position and to permit the legs to dangle from the bed momentarily before standing to reduce the hypotensive effect. The medication does not need to be taken with meals. It may be given without regard to food. If nausea occurs, the client should be instructed to drink a noncola carbonated beverage and eat some salted crackers or dry toast. The full therapeutic effect may take place in 1 to 2 weeks.

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

C. Nausea, thirst, and increased urine output. Rationale: The high glucose concentration in PN puts the client at risk for hyperglycemia. Signs of hyperglycemia include polyuria, polydipsia, polyphagia, blurred vision, nausea and vomiting, and abdominal pain. The nurse checks the blood glucose level immediately if these symptoms develop. The signs and symptoms identified in the other options are unrelated to hyperglycemia.

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

D. Acetylcysteine (Mucomyst). Rationale: Acetylcysteine (Mucomyst) is the antidote to acetaminophen. Pancreatin is a pancreatic enzyme replacement or supplement. Protamine sulfate is the antidote to heparin. Phytonadione is the antidote to warfarin sodium (Coumadin).

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

D. Checking the result of laboratory testing for potassium on the sample drawn 3 hours ago. Rationale: Anorexia and nausea are symptoms commonly associated with digoxin toxicity, which is compounded by hypokalemia. Early clinical manifestations of digoxin toxicity include anorexia and mild nausea, but they are frequently overlooked or not associated with digoxin toxicity. Hallucinations and any change in pulse rhythm, color vision, or behavior should be investigated and reported to the healthcare provider. The nurse should first check the results of the potassium level, which will provide additional when the nurse calls the physician, an important follow-up action. The nurse should also check the digoxin reading if one is available. The nurse would not administer an antiemetic without further investigating the client's problem. Because digoxin toxicity is suspected, the nurse would withhold the digoxin until the physician has been consulted. The nurse would not discontinue a medication without a prescription to do so.

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

D.This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen (Tylenol). Rationale: Headache is a frequent side effect of nitroglycerin, a result of the vasodilating action of the medication. Headaches, which may be treated effectively with the use of acetaminophen (Tylenol), usually diminish in frequency as the client becomes accustomed to the medication. The other options are incorrect.

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

D. Complete blood count (CBC). Rationale: Agranulocytopenia and anemia are common side effects of zidovudine. In some cases lactic acidosis develops. The nurse carefully monitors CBC results for these changes. With early HIV infection or in the client who is asymptomatic, a CBC is performed monthly for 3 months, then every 3 months thereafter. In clients with advanced disease, a CBC is performed every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. The other options are incorrect.

A nurse is preparing a client for the insertion of a central intravenous line into the subclavian vein by the healthcare provider. The nurse gathers the equipment, places it at the bedside, and prepares to assist the healthcare provider with the procedure. As further preparation for the procedure, the nurse places the client:

D. In a slight Trendelenburg position. Rationale: The client is placed in a slight Trendelenburg position. This position is used to increase dilation of the veins and positive pressure in the central veins, reducing the risk of air embolus during insertion. The other options are incorrect because they will not achieve this goal.

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

A. Left side with the head lower than the feet. Rationale: When air embolism is suspected, the client should be placed in a left side-lying position with the head lower than the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. The positions in the other options are incorrect.

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

A. Hypokalemia. Rationale: The client taking a potassium-wasting diuretic such as hydrochlorothiazide must be monitored for reductions in the potassium level. Other fluid and electrolyte imbalances that may occur with use of this medication are hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia. The nurse should also educate the client about foods that are rich in potassium.

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

A. "I'm feeling really drowsy." Rationale: Drowsiness, diarrhea, and hepatotoxicity are the adverse effects of this muscle relaxant, which is used to treat the chronic spasticity seen with spinal cord injury. The drowsiness may interfere with the client's rehabilitation. Relaxed legs are a desired effect. Some clients experience anorexia and urinary frequency.

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

A. Blood bank. Rationale: The nurse returns the transfusion bag, containing any remaining blood, to the blood bank. This allows the blood bank to perform any follow-up testing needed in the event of a documented transfusion reaction. The other options are incorrect because they do not handle post transfusion reaction procedures or testing.

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

A. Cocoa B. Coffee E. Chocolate milk. Rationale: Cola, coffee, and chocolate contain xanthine and should therefore be avoided by the client taking a methylxanthine bronchodilator, because they will enhance the effects of the medication, increasing the likelihood of cardiovascular and central nervous system side effects. Lemonade and orange juice are acceptable choices.

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

A. Liver enzymes. Rationale: INH therapy can increase hepatic enzymes and cause hepatitis. Therefore the client's liver enzymes are assessed when therapy is initiated and during the first 3 months of therapy. Monitoring may be continued further in the client who is older than 50 or abuses alcohol. The other options are not specifically related to the use of this medication.

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

A.0.9% sodium chloride. Rationale: Sodium chloride (normal saline, NS) 0.9% is an isotonic solution that is typically used both to precede and follow infusion of a blood product. Dextrose is not used because it could result in clumping and subsequent hemolysis of RBCs. LR is not the solution of choice for this procedure, even though it is an isotonic solution.

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

A.Fatigue. C. Weakness D.Impotence. Rationale: One common side effect of beta-adrenergic-blocking agents, such as metoprolol, is impotence. Fatigue and weakness are also common. Rarer central nervous system side effects include mental status changes, nervousness, depression, and insomnia. Altered taste, dry eyes, and nightmares are rare side effects.

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

B. "Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?". Rationale: Olanzapine (Zyprexa) is an antipsychotic agent that causes weight gain, a disadvantage of the medication. Weight gain, especially in a young woman, for whom it may be an especially serious blow to self-image, may lead to noncompliance with the medication regimen. "That medication isn't any more likely to cause weight gain than the others you're taking" offers incorrect information. "I think you're overreacting" minimizes the client's complaints. "I want you to stop taking this medication immediately" gives incorrect information and is presented in an unprofessional style.

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

B."I need to report any episodes of palpitations, chest pain, or dyspnea." Rationale: One major concern when initiating thyroid hormone-replacement therapy is that the dose is too high, which can lead to cardiovascular problems. For this reason, clients need to be made aware of the early signs and symptoms of toxicity and urged to report these findings immediately to the physician. Diarrhea, insomnia, and excessive sweating are signs and symptoms of hyperthyroidism; though they may occur with thyroid-replacement therapy, they are not expected and should be reported. Tremors and nervousness are also signs of toxicity, which should be reported. Clients should never take it upon themselves to adjust hormone dosage. Levothyroxine sodium is administered in the morning.

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

C. 45-year-old client who has undergone repair of a hiatal hernia. Rationale: PN is indicated in the client whose gastrointestinal tract is not functional or who cannot tolerate an enteral diet for extended periods. The client with sepsis is very ill and may require PN. Other candidates include clients who have undergone extensive surgery, sustained multiple fractures, or have advanced cancer or AIDS. The client who has undergone hiatal hernia repair is not a candidate, because this client would resume a normal diet within a relatively short period after the hernia repair.

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

C. Hanging a solution of 10% dextrose in water. Rationale: The solution containing the highest amount of dextrose should be hung until the new bag of PN becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose solution is the best solution to infuse because it will minimize the risk of hypoglycemia. The pharmacy and physician should also be called, but care of the client is the immediate priority of the nurse.

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

C.Portable chest x-ray. Rationale: Before beginning the administration of any volume of IV solution through a central venous catheter, the nurse should determine whether the results of the chest x-ray reveal that the catheter is in the proper place. This is necessary to prevent inadvertent infusion of IV fluid into pulmonary or subcutaneous tissues. The other options are items that are useful for the nurse in the general care of the client, but they are not related to this procedure.

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

A. Removing the IV catheter at that site B.Applying warm, moist compresses to the IV site C. Notifying the healthcare provider about the finding. Rationale: The nurse should remove the IV from the phlebitic site and apply warm, moist compresses to the area to speed resolution of the inflammation. The nurse also notifies the physician of this complication. The nurse should restart the IV line in a vein other than the one in which phlebitis has developed. The nurse should discourage the client from rubbing the site while in the shower, because this could cause sloughing of the tissue.

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

A. Dementia. Rationale: Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer type. It enhances cholinergic function by increasing the concentration of acetylcholine, slowing the progression of Alzheimer disease. The disorders in the other options are not treated with this medication.

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

A. Monitoring intake and output. Rationale: Urine retention is a side effect of benztropine mesylate (Cogentin). The nurse must be alert for infrequent voiding of small amounts, which may be indicative of urine retention, dysuria, abdominal distention, or overflow incontinence. This monitoring is also an important intervention for the client with heart failure. Monitoring pupillary response and checking the client's hemoglobin level daily are not interventions specific to this medication. The client with heart failure is placed in an upright position to facilitate breathing.

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

A.Monitor the client's urine output. Rationale: Amphotericin B can produce medication toxicity during administration and exhibit symptoms such as chills, fever, headache, vomiting, and impairment of renal function. The medication is also irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication watches for all of these problems. The other options are not specifically related to the administration of this medication.

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

A.Weight B.Glucose test C.Temperature. Rationale: When a client is receiving PN therapy, the nurse monitors the client's weight to determine the effectiveness of the therapy. The nurse should weigh the client at each visit to make sure that the client has not gained or lost an excessive amount of weight. Because the formula contains a large amount of dextrose, the healthcare provider should check the client's glucose level frequently. The nurse caring for a client receiving PN at home should also monitor the temperature to detect infection, which is a potential complication of this therapy. An infection in the intravenous line could result in sepsis, because the catheter is in a blood vessel. The peripheral pulses and hemoglobin and hematocrit readings may provide data but are unrelated to complications associated with PN therapy.

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

B. 1330. Rationale: Blood must be hung within 30 minutes after obtaining it from the blood bank. After that time, the temperature of the blood becomes warm and could be unsafe for use. Therefore 1345 and 1400 are incorrect. It is not necessary to hang the blood within 15 minutes of receiving it from the blood bank.

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

B. Contacting the healthcare provider. Rationale: If the nurse suspects a transfusion reaction, the transfusion is stopped and normal saline solution infused at a keep-vein-open rate pending further physician prescriptions. The nurse then contacts the physician. Dextrose in water is not used, because it may cause clotting or hemolysis of blood cells. Normal saline solution is the only type of IV fluid that is compatible with blood. The nurse would not remove the IV catheter, because then there would be no IV access route through which to treat the reaction. There is no reason to obtain a culture of the catheter tip; this is done when an infection is suspected.

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

B. Drink at least 8 glasses of fluid every day. Rationale: Clients taking allopurinol are encouraged to drink 3000 mL/day of fluid. Allopurinol is to be given with or immediately after meals or milk. If a rash, irritation of the eyes, or swelling of the lips or mouth develops, the client should contact the physician, because this development may indicate hypersensitivity.

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

B. Questioning the healthcare provider about the prescription. Rationale: PN solutions containing as much as 10% glucose can be infused through peripheral vessels. A PN solution containing 25% glucose is hypertonic. The nurse should question the prescription in the absence of a central venous catheter or a peripherally inserted central catheter. Diluting the solution with sterile water to half-strength and hanging the IV solution as prescribed are both inappropriate. The nurse must not alter a prescribed solution independently.

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

C.Bananas D.Citrus fruits. Rationale: Spironolactone is a potassium-sparing diuretic. Hyperkalemia is the principal adverse effect. Clients are instructed to restrict their intake of potassium-rich foods, such as citrus fruits and bananas. Rice, cereal, and carrots are appropriate foods for the daily diet.

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

D. Sterile 2 × 2 gauze. Rationale: A dry sterile dressing such as a 2 × 2 is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. An adhesive bandage may be used to cover the site once hemostasis has occurred. A povidone-iodine swab or alcohol swab would irritate the opened puncture site and would not stop the blood flow.

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

D. Tightness of the tubing connections. Rationale: A loose tubing connection — the most obvious cause of the moisture that could be readily detected and fixed by the nurse — is the first thing the nurse should look for. The client's temperature would be assessed if the nurse were looking for signs of infection. The expiration date on the infusion bag and the time of the last dressing change are routine observations but have nothing to do with the subject of the question.

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

B. Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed. Rationale: Nitroglycerin is a coronary vasodilator used in the management of angina pectoris. The client is generally advised to apply a new patch at the same time each day (usually each morning) and leave in place for 12 to 16 hours as per physician directions. This prevents the client from developing tolerance (such as that which happens with 24-hour use). The client should avoid placing patches in skin folds or excoriated areas. The client benefits from removing the patch for sleep as well, because the nitroglycerin may cause a headache, which could disrupt sleep. The client may apply a new patch if the old one is dislodged, because the dose is released continuously in small amounts through the skin.

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

B. Requesting a new bottle from the pharmacy. Rationale: The nurse should not hang a fat emulsion that contains visible fat globules. Another bottle of solution should be obtained and used in its place. When PN is combined with fat emulsion, the solution should not be used if there is a visible "ring" noted in the container of solution. The actions in the other options are incorrect.

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

C. It is important to decrease fluid intake while taking the medication to avoid nausea. Rationale: Because the therapeutic and toxic dosage ranges are so close, the blood level of lithium in a client taking the medication must be monitored closely; assessments are performed frequently at first and every several months after that. The client should be instructed to stop taking the medication if excessive diarrhea, vomiting, or diaphoresis occurs and to inform the physician if any of these problems develops. Lithium is irritating to the gastric mucosa; therefore lithium should be taken with meals. A normal diet and normal salt and fluid intake (1500 to 3000 mL/day of fluid) should be maintained, because lithium decreases sodium reabsorption in the renal tubules, which may result in sodium depletion. Low sodium intake causes an increase in lithium retention and could lead to toxicity.

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

C. Uterine hyperstimulation. Rationale: Oxytocin, a synthetic hormone that stimulates uterine contractions, is a commonly used pharmacological means of inducing labor. One major concern associated with oxytocin is hyperstimulation of uterine contractions. Hyperstimulation of the uterus, which may result in diminished placental perfusion, may cause fetal distress. Therefore an oxytocin infusion must be stopped if there are any signs of uterine hyperstimulation. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress. Uterine atony and severe drowsiness are not indications of the need to discontinue the infusion.

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

A. Akathisia. Rationale: Approximately 5 to 60 days after starting an antipsychotic medication, the client may exhibit the side effect of akathisia, manifested by motor restlessness (continually tapping a foot, rocking back and forth in a chair, or shifting weight from one foot to another). Pelvic thrusts, athetoid limbs, and a protruding tongue are effects that may occur after 6 to 24 months of an antipsychotic medication.

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

A. Phlebitis of the vein. Rationale: Phlebitis at an IV site can be identified by client discomfort at the site, as well as by redness, warmth, and swelling in the area of the catheter. The IV should be removed and a new one inserted at a different site. The remaining options are incorrect. Coolness and swelling would be noted if infiltration had occurred. The symptoms of hypersensitivity and allergic reaction depend on whether these complications are local or systemic.

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

B. Vital signs. Rationale: A change in vital signs may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure, every 15 minutes for the first half-hour, and every half-hour thereafter. The other options do not need to be assessed just before the start of a transfusion. The nurse should be aware of fluid volume status, as well as weight. to help identify fluid volume overload, but this is not the priority before start of a blood infusion.

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

B. Clamps the PN infusion line. Rationale: One complication of a subclavian central line is embolism, caused by air or thrombus. Sudden onset of chest pain shortly after the initiation of PN may mean that this complication has developed. The infusion is clamped (the line should not be discontinued, however), the client turned on the left side with the head down, and the physician notified immediately. Depending on agency protocol, the rapid response team would also be called. Blood cultures are not necessary in this situation, because infection is not the concern. Likewise, there is no useful reason for checking the blood glucose level. An ECG may be obtained, but this is not the immediate priority. If the client shows signs of an air embolism, the nurse should examine the catheter to determine whether an open port has allowed air into the circulatory system