Passpoint 5

A client is to be discharged on daily medication delivered by a transdermal disk. Which statement indicates the need for further medication teaching? "I'll place the disk on the same spot each day." "I'll wash my hands after applying the disk." "I'll change the disk at the same time every day." "I'll avoid touching the gel in the disk."

"I'll place the disk on the same spot each day." Explanation: A transdermal disk should be applied to a different site each time. The client should avoid placing the disk on uneven, damaged, or irritated skin or on areas below the knee or elbow. The other options indicate that the client understands how to use the transdermal disk.

levonergestrel

Plan B

During surgery, a client develops sinus bradycardia. The physician orders atropine sulfate. Which dose and route should the nurse use? 0.6 mg I.M. 1 mg I.V. 2 mg I.M. 2 mg I.V.

1 mg I.V. Explanation: To reverse arrhythmias, bradycardia, or sinus arrest, the usual adult dosage of atropine is 0.5 to 1 mg I.V. every 3 to 5 minutes as needed. The drug isn't administered I.M. for the treatment of bradycardia.

expectorant

a drug that breaks up mucus and promotes coughing

Guaifenesin

expectorant, Mucinex, Robitussin

A client who is receiving a blood transfusion suddenly experiences chills and a temperature of 101° F (38° C) The client also has a headache and appears flushed. In what order, from first to last, should the nurse perform the actions? All options must be used. 1 Stop the blood infusion. 2 Infuse normal saline to keep the vein open. 3 Obtain a blood culture from the client. 4 Send the blood bag and administration set to the blood bank.

Stop the blood infusion. Infuse normal saline to keep the vein open. Obtain a blood culture from the client. Send the blood bag and administration set to the blood bank. Explanation: The client is experiencing a septic reaction to the blood transfusion. The nurse first stops the infusion and notifies the health care provider (HCP) and blood bank; then the nurse uses an infusion of normal saline to keep the vein open, and follows by obtaining a sample of the client's blood for a blood culture. Lastly, the nurse sends the blood bag and the administration set to the blood bank for culture.

An older adult who experienced a brief delirium realizes that the condition was caused by prescription medication intoxication. Which of the following statements indicates the need for further education?

"I get medicines from three different doctors and they don't all know what I'm taking."

Which of the following statements indicates that a client understands discharge instructions about propranolol? "I will assess my heart rate before I take my medication." "I will not take this medication if I see yellow halos around lights." "I will take this medication in the morning." "I will take this medication whenever I feel anxious."

"I will assess my heart rate before I take my medication." Explanation: The therapeutic effect of propranolol is to lower the heart rate. Generally, clients should assess and call their healthcare provider if their heart rate drops below 55 beats per minute. Yellow halos indicate digoxin toxicity. The time of day when this medication is taken does not matter. Propranolol is not used as a taken-as-needed medication for anxiety.

The nurse is counseling a client regarding treatment of the client's newly diagnosed depression. The nurse emphasizes that full benefit from antidepressant therapy usually takes how long? 1 week 2 to 4 weeks 5 to 7 weeks 8 weeks

2 to 4 weeks Explanation: Full benefit from an antidepressant medication usually takes about 2 to 4 weeks on an adequate dose.

In preparing for insertion of a peripheral I.V. catheter, the nurse must select an appropriate site. Which of the following areas should the nurse try first if an appropriate vein is found? Back of the hand. Inner aspect of the elbow. Inner aspect of the forearm. Outer aspect of the forearm.

Back of the hand. Explanation: When inserting an I.V. catheter needle, the nurse initially uses veins low on the hand or arm if available, unless contraindicated. Should the I.V. fluid infiltrate or the vein become irritated at this insertion site, veins higher on the arm are still available for use. After a vein higher up on the arm has been damaged, veins below it cannot be used.

During clindamycin therapy, a nurse monitors a client for pseudomembranous colitis. This serious adverse reaction to clindamycin results from superinfection with which organism? Staphylococcus aureus Bacteroides fragilis Escherichia coli Clostridium difficile

Clostridium difficile Explanation: Pseudomembranous colitis may result from a superinfection with C. difficile during clindamycin therapy. Clindamycin-induced pseudomembranous colitis isn't caused by S. aureus, B. fragilis, or E. coli.

A RN preceptor is assisting a new graduate to access a port-a-cath with a Huber needle. Which action by the new graduate would require intervention by the RN preceptor? Insertion of the needle at 90 degrees through the skin. Wearing a surgical mask during the procedure. Wearing sterile gloves during the procedure. Rotation of the needle immediately after access.

Rotation of the needle immediately after access. Explanation: Accessing a port-a-cath is a sterile procedure which requires a mask and sterile gloves. The needle should be placed at a 90 degree angle and should NOT be rotated as this may damage the port.

Stevens-Johnson Syndrome

SE for Lamotrigine; Stevens-Johnson syndrome is a rare, serious disorder of your skin and mucous membranes. It's usually a reaction to a medication or an infection. Often, it begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters.

Preciptate

a solid that forms and settles out of a liquid mixture

A client receiving a loop diuretic should be encouraged to eat which foods to prevent potassium loss? Select all that apply. angel food cake banana dried fruit orange juice peppers

banana dried fruit orange juice Explanation: Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake and peppers are low in potassium.

A nurse is caring for a client with a long-term central venous catheter. Which steps should the nurse include in teaching how to care for his catheter at home? Use clean technique when accessing the port with a needle. If the needle becomes contaminated before accessing the port, clean the needle with povidone-iodine solution. Clean the port with an alcohol pad before administering I.V. fluid through the catheter. Flush each port using a 10ml NSS syringe, giving each port 5ml from the syringe.

Clean the port with an alcohol pad before administering I.V. fluid through the catheter. Explanation: Clients should be instructed to clean the port with an alcohol pad before administering I.V. fluid through the catheter to prevent microorganisms from entering the bloodstream. Using clean technique when accessing the port with a needle, cleaning the needle with a povidone-iodine solution, or flushing each port using the same syringe would break sterile technique.

The nurse should suspect that the client taking disulfiram has ingested alcohol when the client exhibits which symptom? sore throat and muscle aches nausea and flushing of the face and neck fever and muscle soreness bradycardia and vertigo

nausea and flushing of the face and neck Explanation: The client who drinks alcohol while taking disulfiram experiences sweating, flushing of the neck and face, tachycardia, hypotension, a throbbing headache, nausea and vomiting, palpitations, dyspnea, tremor, and weakness.

A nurse is assessing a client who is receiving clozapine. The nurse reviews the medical record. What should the nurse do next?

Withhold the clozapine, and notify the health care provider (HCP). Explanation: Because clozapine can cause tachycardia, the nurse should withhold the medication if the pulse rate is greater than 140 bpm and notify the HCP. Giving the drug or telling the client to exercise could be detrimental to the client.

A nurse is aware that antipsychotic medications may cause: increased insulin production. lower seizure threshold. increased coagulation time. increased risk of heart failure.

lower seizure threshold. Explanation: Antipsychotic medications affect brain neurotransmitters in a way that lowers the seizure threshold and can, therefore, increase the risk of seizure activity. Antipsychotics don't affect insulin production or coagulation time. Heart failure isn't an adverse effect of antipsychotic agents.

The nurse is assessing a client for heroin addiction. Which finding indicates the client has used heroin? sclera red and bloodshot pupils small and constricted pupils large and dilated drooping eyelids

pupils small and constricted Explanation: Heroin causes pinpoint pupils. Marijuana causes the eyes to appear red and bloodshot. Cocaine use causes pupils to dilate. Drooping of the eyelids is not typically associated with the use of any substance.

A client taking oral contraceptives is placed on a 10-day course of antibiotics for an infection. Which instruction should the nurse include in the teaching plan? "Use a barrier method of birth control for the rest of your cycle." "You should stop taking the oral contraceptives while taking the antibiotic." "Call your health care provider for increased hunger or fluid retention." "Take the antibiotics 2 hours after the oral contraceptive."

"Use a barrier method of birth control for the rest of your cycle." Explanation: Antibiotics may decrease the effectiveness of oral contraceptives. The client should be instructed to continue the contraceptives and use a barrier method as a backup method of birth control until the next menstrual cycle. The client should not stop taking her oral contraceptives, and there is no indication for or benefit to taking the antibiotic 2 hours after the contraceptive. There is no incidence of the adverse effects of increased hunger and fluid retention with the interaction of antibiotic therapy and oral contraceptives.

Which technique is appropriate when the nurse is irrigating an adult client's ear to move cerumen? Allow the irrigating solution to run down the wall of the ear canal. Use sterile solution and equipment. Make sure the irrigating solution is cool. After instilling the solution, pack the ear canal tightly with a cotton ball.

Allow the irrigating solution to run down the wall of the ear canal. Explanation: The irrigating solution should not be allowed to drop directly on the tympanic membrane because this may cause discomfort or damage. Ear irrigation is considered to be a clean procedure unless the integrity of the tympanic membrane has been damaged. The solution should be at body temperature; when instilled, it should be allowed to run down the side of the ear canal. A cotton ball should be placed loosely in the ear canal so it does not exert pressure on the tympanic membrane.

Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next? Withhold the lithium, and obtain a stat lithium level to determine therapeutic effectiveness. Continue the lithium, and immediately notify the health care provider (HCP) about the assessment findings. Continue the lithium, and reassure the client that these temporary side effects will subside. Withhold the lithium, and monitor the client for signs and symptoms of increasing toxicity.

Continue the lithium, and reassure the client that these temporary side effects will subside. Explanation: The client is exhibiting temporary side effects associated with beginning lithium therapy. Therefore, the nurse should continue the lithium and explain to the client that the temporary side effects of lithium that will subside. Common side effects of lithium are nausea, dry mouth, diarrhea, thirst, mild hand tremor, weight gain, bloating, insomnia, and light-headedness. Immediately notifying the HCP about these common side effects is not necessary.

When explaining the long-term toxic effects of cancer treatments on the immune system, what should the nurse tell the client? Clients with persistent immunologic abnormalities after treatment are at a much greater risk for infection than clients with a history of splenectomy. The use of radiation and combination chemotherapy can result in more frequent and more severe immune system impairment. Long-term immunologic effects have been studied only in clients with breast and lung cancer. The helper T cells recover more rapidly than the suppressor T cells, which results in positive helper cell balance that can last 5 years.

The use of radiation and combination chemotherapy can result in more frequent and more severe immune system impairment. Explanation: Studies of long-term immunologic effects in clients treated for leukemia, Hodgkin's disease, and breast cancer reveal that combination treatments of chemotherapy and radiation can cause overall bone marrow suppression, decreased leukocyte counts, and profound immunosuppression. Persistent and severe immunologic impairment may follow radiation and chemotherapy (especially multiagent therapy). There is no evidence of greater risk of infection in clients with persistent immunologic abnormalities. Suppressor T cells recover more rapidly than the helper T cells.

An older client with diabetes who has been maintained on metformin has been scheduled for a cardiac catheterization. The nurse should verify that the health care provider (HCP) has written which prescription for taking the metformin before the procedure? Increase the amount of protein in the diet the day before. Withhold the metformin. Administer the metformin with only a sip of water. Give the metformin before breakfast.

Withhold the metformin. Explanation: The nurse should verify that the HCP has requested to withhold the metformin prior to any procedure requiring dye such as a cardiac catheterization due to the increased risk of lactic acidosis. Additionally, the drug will usually be withheld for up to 48 hours following a procedure involving dye while it clears the client's system. The HCP may prescribe sliding scale insulin during this time if needed. Regardless of how or when the medication is administered, the medication should be withheld. The amount of protein in the client's diet prior to the cardiac catheterization has no correlation with the medication or the test.

A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing: deeper sleep than CNS depressants. greater sedation than CNS depressants. a calming effect from which the client is easily aroused. more prolonged sedative effects, making the client more difficult to arouse.

a calming effect from which the client is easily aroused. Explanation: Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.

Before the nurse administers IV replacement of 5% dextrose in water with potassium chloride, what nursing intervention must be completed first? adding potassium chloride to the bag at the bedside evaluating laboratory results for electrolytes priming tubing using sterile technique checking the rate for IV push administration.

evaluating laboratory results for electrolytes Explanation: IV solutions are prescribed based upon the fluid and electrolyte status of the client, so laboratory results should be monitored first. Safety recommendations are for standard premixed solutions. If solutions are not premixed, additives are completed by the pharmacy, not at the bedside. Potassium chloride is never given by IV push because this could be fatal. Administration guidelines require no more than 10 mEq (10 mmol/L) of potassium chloride be infused per hour on a general medical-surgical unit. An infusion device or pump is required for safe administration.

A client is receiving a transfusion of packed red blood cells. To safely administer the blood, the nurse should: keep the blood refrigerated on the nursing unit until ready to administer. stay with the client during the first 15 minutes to detect signs or symptoms of a reaction. do not infuse blood that has been hanging for more than 6 hours. administer the blood quickly to prevent wasting it if the client develops a fever.

stay with the client during the first 15 minutes to detect signs or symptoms of a reaction. Explanation: The nurse should stay with the client during the first 15 minutes of a blood transfusion because this is when reactions are most likely to occur. Blood products should never be refrigerated on the nursing unit. Blood that has not been infused after 4 hours should not be infused. The blood should be infused over the specific time prescribed by the health care provider (HCP). If a fever develops, the transfusion should be stopped immediately, and the blood reaction policy of the facility should be followed.

A 14-year-old is using glargine and lispro to manage type 1 diabetes. The prescription for sliding scale lispro reads as follows: Lispro subcutaneous give units according to sliding scale: Blood glucose: 70-150 mg/dL (3.9 to 8.3 mmol/L) = 0 units 151-200 mg/dL (8.4 to 11.1 mmol/L) = 1 unit 201-250 mg/dL (11.2 to 13.9 mmol/L) = 2 units 251-300 mg/dL (13.9 to 16.7 mmol/L) = 3 units 301-350 mg/dL (17 to 19.4 mmol/L) = 4 units Call for Blood glucose > 350 mg/dL (19.4 mmol/L) In addition give 1 unit for every 15 g of carbohydrate. The morning blood glucose is 202 mg/dL (11.2 mmol/L), and the client is going to eat two carbohydrate exchanges. The nurse has the client administer how many units of lispro? Record your answer using a whole number.

4 Explanation: Each carbohydrate food exchange has 15 g of carbohydrate. Two units are needed to cover the current blood glucose and 2 units are needed to cover the anticipated carbohydrate intake.

A client is diagnosed with iron deficiency anemia. When teaching the caregivers about using supplemental iron elixir, the nurse should provide which instruction? "Give the iron preparation with milk." "Give the elixir with water or juice." "Monitor the child for episodes of diarrhea." "Give the iron preparation before meals."

"Give the elixir with water or juice." Explanation: Because iron preparations may stain the teeth, the nurse should instruct the caregivers to give the elixir with water or juice. The iron preparation shouldn't be given with milk because milk impedes iron absorption. This preparation may darken the stools and cause constipation, not diarrhea; instruction to the caregivers regarding increased fluid intake and fiber intake can relieve constipation. To prevent GI upset, the nurse should instruct the caregivers to mix the iron preparation with water or fruit juice and have the client take it with, not before, meals. (Giving it with fruit juice may be preferable because vitamin C enhances iron solubility and absorption.)

The nurse is teaching a client how to apply nitroglycerin topical ointment. Which statement indicates that the client needs additional clarification of the instructions? "I will use the applicator paper to measure the amount of ointment I should use." "It is important that I rotate the application sites to avoid skin irritation." "I should remove any remaining old ointment with a tissue before applying a new dose." "I will carefully massage the ointment into the skin."

"I will carefully massage the ointment into the skin." Explanation: The client should not rub or massage the ointment into the skin. The ointment should be allowed to absorb slowly. The client should use the applicator paper to measure the amount of ointment to apply. The client should rotate the application sites to avoid skin irritation. The client should remove any remaining ointment with a tissue before applying a new dose.

A client with bipolar disorder has been taking lithium carbonate for the past 2 years. Recently, the client has been experiencing a recurrence of manic symptoms approximately once a month. The client's psychiatrist has added clonazepam to help manage the client's mood swings. Which of the following statements should the nurse include in medication teaching? "This medication may cause a severe rash, which should be reported to your physician immediately." "This medication should not be taken with any other medication." "This medication will help steady your moods by reducing the overstimulation of chemical messengers in your brain." "This medication should not be taken with foods that contain tyramine, such as aged cheese."

"This medication will help steady your moods by reducing the overstimulation of chemical messengers in your brain." Explanation: This response provides a simple explanation of how anticonvulsants help treat manic symptoms in people experiencing rapid mood swings caused by kindling. It is commonly prescribed in conjunction with lithium carbonate and other psychotropic medications. Dietary restrictions are unnecessary unless the client is taking a monoamine oxidase inhibitor. Although a rash or allergic response is always a possibility with any medication, lamotrigine, not clonazepam is the anticonvulsant most likely to cause Stevens-Johnson syndrome.

A 12-year-old child sustains a moderate burn injury. The mother reports that the child last received a tetanus injection when he was five years old. Which immunization would the nurse anticipate an for this child? 0.5 ml of tetanus toxoid IM 0.5 ml of tetanus toxoid IV 250 units of tetanus immune globulin IM 250 units of tetanus immune globulin IV

0.5 ml of tetanus toxoid IM Explanation: Tetanus prophylaxis is given to all clients with moderate to severe burn injuries if it has been longer than five years since the last immunization, or if there is no history of immunization. The correct dosage is 0.5 ml IM, one time, if the child was immunized within 10 years. If it has been more than 10 years, or the child hasn't received tetanus immunization, the dosage is 250 units of tetanus immune globulin, one time. There is no IV form of tetanus immune globulin available.

Phenytoin

Dilantin Anticonvulsant

A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively? Elevating the hand and wrapping it in a warm towel Placing an ice pack on the hand Administering an as-needed analgesic Wrapping the arm in an elastic bandage from wrist to elbow

Elevating the hand and wrapping it in a warm towel Explanation: Elevating the arm promotes venous drainage and reduces edema; applying warmth increases circulation and eases pain and edema. Ice application would relieve pain but not edema. An analgesic wouldn't correct the primary cause of the discomfort. Wrapping the arm above the hand would slow venous return and is contraindicated.

A client with a retroperitoneal abscess is receiving gentamicin. Which signs should the nurse monitor? Select all that apply. Hearing Urine output Hematocrit (HCT) Blood urea nitrogen (BUN) and creatinine levels Serum calcium level

Hearing Urine output Blood urea nitrogen (BUN) and creatinine levels Explanation: Adverse reactions to gentamicin include ototoxicity and nephrotoxicity. The nurse must monitor the client's hearing and instruct him to report any hearing loss or tinnitus. Signs of nephrotoxicity include decreased urine output and elevated BUN and creatinine levels. Gentamicin doesn't affect the serum calcium level or HCT.

The nurse administers phenytoin 125 mg by mouth twice daily to a 6 year old child who is diagnosed with complex partial seizures. The nurse is most concerned about phenytoin toxicity when the child also has a disorder of which of the following organs? Pancreas Kidneys Stomach Liver

Liver Explanation: Phenytoin is metabolized in the liver. The pancreas isn't involved in the pharmacokinetic activity of phenytoin. The stomach absorbs orally administered phenytoin, which is excreted by the kidneys in the urine.

A laboring client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. Which medication would the nurse anticipate for these symptoms? Terbutaline Oxytocin Magnesium sulfate Calcium gluconate

Magnesium sulfate Explanation: Magnesium sulfate is the drug of choice to treat hypertension of pregnancy because it reduces edema by causing a shift from the extracellular spaces into the intestines. It also depresses the central nervous system, which decreases the incidence of seizures. Terbutaline is a smooth muscle relaxant used to relax the uterus. Oxytocin is the synthetic form of the pituitary hormone used to stimulate uterine contractions. Calcium gluconate is the antagonist for magnesium toxicity.

A short time after cataract surgery, the client has nausea. What should the nurse do first? Instruct the client to take a few deep breaths until the nausea subsides. Explain that this is a common feeling that will pass quickly. Tell the client to call the nurse promptly if vomiting occurs. Medicate the client with an antiemetic, as prescribed.

Medicate the client with an antiemetic, as prescribed. Explanation: A prescribed antiemetic should be administered as soon as the client has nausea following a cataract extraction. Vomiting can increase intraocular pressure, which should be avoided after eye surgery because it can cause complications. Deep breathing is unlikely to relieve nausea. Postoperative nausea may be common; however, it does not necessarily pass quickly and can lead to vomiting. Telling the client to call only if vomiting occurs ignores the client's need for comfort and intervention to prevent complications.

The nurse observes which principles when conducting a medication reconciliation? Select all that apply. Medication reconciliation is an important client safety goal. Medication reconciliation is designed to obtain and communicate an accurate list of a client's home medications across the continuum of care. Only nurses or health care providers (HCPs) can be involved in medication reconciliation. Medications are considered reconciled if a medication prescription exists that is therapeutically equivalent to the one prior to admission. A medication is considered to be any medication prescribed by a health care provider (HCP).

Medication reconciliation is an important client safety goal. Medication reconciliation is designed to obtain and communicate an accurate list of a client's home medications across the continuum of care. Medications are considered reconciled if a medication prescription exists that is therapeutically equivalent to the one prior to admission. Explanation: A National Patient Safety Goal of The Joint Commission is to accurately and completely reconcile medications across the continuum of care. The requirement is that there is a process for comparing the client's current medications with those prescribed for the client while under the care of the health care organization. Clients are most at risk during transitions in care (hand-offs) across settings, services, providers, or levels of care. The development, reconciliation, and communication of an accurate medication list throughout the continuum of care are essential in the reduction of transition-related adverse drug events. The client or client's family is an integral component of medication reconciliation, particularly at the point of admission to, and discharge from, a health care facility. Any medications that the client uses, for example, over-the-counter medications, must be included in the reconciliation process.

The client is taking 50 mg of lamotrigine daily for bipolar depression. The client shows the nurse a rash on his arm. What should the nurse do? Report the rash to the health care provider (HCP). Explain that the rash is a temporary adverse effect. Give the client an ice pack for his arm. Question the client about recent sun exposure.

Report the rash to the health care provider (HCP). Explanation: The nurse should immediately report the rash to the HCP because lamotrigine can cause Stevens-Johnson syndrome, a toxic epidermal necrolysis. The rash is not a temporary adverse effect. Giving the client an ice pack and questioning the client about recent sun exposure are irresponsible nursing actions because of the possible seriousness of the rash.

The nurse just started an infusion of blood on a client. A few minutes pass and the client develops a sudden fever. What are the priority interventions by the nurse? Select all that apply. Start the normal saline infusion. Continue to monitor vital signs. Stop the blood infusion. Notify the healthcae provider. Force oral fluids.

Start the normal saline infusion. Continue to monitor vital signs. Stop the blood infusion. Notify the healthcae provider. Explanation: Development of fever during blood transfusion can indicate a transfusion reaction. The appropriate nursing action is to discontinue the blood transfusion, infuse normal saline to prevent a more severe reaction, continue to monitor vital signs, and call the healthcare provider. Other interventions include serum analysis of BUN and creatinine, and returning the blood and tubing to the laboratory to be analyzed. Forcing oral fluids is not part of transfusion reaction care.

A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect? The ventricular rate is increasing. The absent pulse is now palpable. The number of premature ventricular contractions is decreasing. The fine ventricular fibrillation changes to coarse ventricular fibrillation.

The number of premature ventricular contractions is decreasing. Explanation: Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.

A child has discomfort and swelling around the IV insertion site. The nurse should first determine if the: angiocatheter has come out of the vein. IV site has been used too long. child is allergic to the plastic in the angiocatheter. rate of fluid administration is too rapid for the vein size.

angiocatheter has come out of the vein. Explanation: Pain and swelling around the IV insertion site most likely indicates that the angiocatheter has come out of the vein. Swelling occurs as the fluid infuses into subcutaneous tissues. Other typical signs of infiltration include skin pallor and coldness around the insertion site. Signs of inflammation, such as redness and warmth, are likely if the IV site is used too long. Because inert plastic is used for manufacturing IV catheters, the risk of an allergic reaction is remote. If fluid is administered too rapidly for the vein size, the fluid would most probably leak around the angiocatheter at the area of connection with the tubing.

The health care provider (HCP) has prescribed intravenous mannitol for a child with a head injury. The best indicator that the drug has been effective is which assessment finding? increased urine output. improved level of consciousness. decreased intracranial pressure. decreased edema.

decreased intracranial pressure. Explanation: Mannitol is an osmotic diuretic used to reduce intracranial pressure. The use of the drug is controversial and should be reserved to cases that do not respond to other treatments or when brain herniation is likely. Children this sick should be on intracranial pressure (ICP) monitoring. The best indicator that the drug has produced the desired results is a reduction in the ICP. Improved levels of consciousness should follow reduced ICP. While the drug will cause increased urine output, that measurement in and of itself does not indicate successful treatment. Because the drug is being used for head injuries, not to improve urine output in acute renal failure, the child may not have visible edema.

A physician orders lithium carbonate for a client who has just been diagnosed with bipolar disorder. The nurse is teaching the client about signs and symptoms of lithium toxicity, which include: skeletal muscle contractions, cogwheel rigidity, and a thick tongue. dry mouth, blurred vision, and urine retention. edema, orthostatic hypotension, and rash. lethargy, vomiting, and diarrhea.

lethargy, vomiting, and diarrhea. Explanation: Lethargy is an early sign of lithium toxicity; if it goes undetected, vomiting and diarrhea soon develop. Lithium doesn't cause extrapyramidal effects, such as skeletal muscle contractions, cogwheel rigidity, and a thick tongue, or cholinergic effects, such as dry mouth, blurred vision, and urine retention. The drug also doesn't cause edema, orthostatic hypotension, or rash.

Which medication is appropriate to administer, if prescribed, to a client experiencing symptoms of early alcohol withdrawal? disulfiram lorazepam quetiapine temazepam

lorazepam Explanation: Antianxiety agents such as lorazepam and chlordiazepoxide are commonly used to ease symptoms during early alcohol withdrawal. Disulfiram is an alcohol deterrent used to maintain sobriety. Quetiapine is an atypical antipsychotic used to manage the symptoms of schizophrenia. Temazepam is a sedative-hypnotic not used for alcohol withdrawal.

A client will be discharged on lithium carbonate 600 mg three times daily. When teaching the client and his family about lithium therapy, the nurse determines that teaching has been effective if the client and family state that they will notify the prescribing health care provider (HCP) immediately which symptoms? Select all that apply. nausea muscle weakness vertigo fine hand tremor vomiting anorexia

muscle weakness vertigo vomiting Explanation: Serious side effects that may indicate lithium toxicity include muscle weakness, vertigo, vomiting, extreme hand tremor, and sedation. The prescribing HCP should be notified immediately when these symptoms occur. When lithium is initiated, mild or transient side effects can occur, such as nausea, fine hand tremor, anorexia, increased thirst and urination, and diarrhea or constipation.

A client is receiving captopril for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals: skin rash. peripheral edema. dry cough. postural hypotension.

peripheral edema. Explanation: Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.

A client's medication order reads, "Thioridazine 200 mg P.O. q.i.d. and 100 mg P.O. p.r.n." A nurse should: administer the medication as ordered. question the physician about the order. administer the order for 200 mg P.O. q.i.d. but not for 100 mg P.O. p.r.n. administer the medication as ordered but observe the client closely for adverse effects.

question the physician about the order. Explanation: The nurse must question this order immediately. Thioridazine has an absolute dosage ceiling of 800 mg/day. Any dosage above this level places the client at high risk for toxic pigmentary retinopathy, which can't be reversed. As written, the order allows for administering more than the maximum 800 mg/day; it should be corrected immediately, before the client's health is jeopardized.

A toddler with croup is given a racemic epinephrine treatment because of increasing respiratory distress. The nurse evaluates the treatment as being effective when the child's: color is normal. retractions are less severe. heart rate is 100 bpm. pulse oximeter reads 90.

retractions are less severe. Explanation: Epinephrine in an inhalant form can be given to decrease inflammation in the upper airway through vasoconstriction. It also has bronchodilator effects. In the case of croup, epinephrine is used to increase the opening of the narrowed airway. A decrease in the severity of retractions is the only answer indicating a change that reflects an increase in the airway opening. Children with croup may not manifest with color change. A heart rate of 100 is normal for a toddler and tells the nurse very little about a child's degree of respiratory distress. While no data is given to show that the pulse oximeter reading was improving, a oxygen saturation of less than 92% in room air reflects suboptimal oxygenation.

A client was admitted to the hospital because of a transient ischemic attack (TIA) secondary to atrial fibrillation. The nurse anticipates that the provider will prescribe: digoxin. diltiazem. warfarin. quinidine gluconate.

warfarin. Explanation: Atrial fibrillation may lead to the formation of mural thrombi, which may embolize to the brain. Warfarin will prevent further clot formation and prevent clot enlargement. The other drugs are used in the treatment and control of atrial fibrillation, but won't affect clot formation.

A client has obtained levonorgestrel as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which statement? "I can wait up to 4 days after intercourse to start taking these to prevent pregnancy." "My boyfriend can buy levonorgestrel from the pharmacy if he is over 18 years old." "The birth control works by preventing ovulation or fertilization of the egg." "I may feel nauseated and have breast tenderness or a headache after using the contraceptive."

"I can wait up to 4 days after intercourse to start taking these to prevent pregnancy." Explanation: Levonorgestrel can reduce the chance of pregnancy if taken within 72 hours of unprotected intercourse, but pills are most effective if taken immediately after unprotected intercourse and then again 12 hours later,. Males can purchase this contraceptive as long as they are over 18 years of age. Levonorgestrel works by preventing ovulation or fertilization depending on where a client is the menstrual cycle. Common side effects include nausea, breast tenderness, vertigo, and stomach pain.

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition? Accelerating the infusion if it falls behind schedule Ensuring that the TPN tubing has an in-line filter Monitoring the client's weight every day Recording fluid intake and output

Monitoring the client's weight every day Explanation: By weighing the client every day, the nurse helps the team evaluate the client's response to TPN. Maintenance of the current weight is one indicator of adequate nutrition; weight loss may indicate inadequate nutrition, whereas weight gain may indicate adequate nutrition or fluid retention. The nurse shouldn't accelerate a TPN infusion that has fallen behind because this can cause wide fluctuations in the blood glucose level. Use of an in-line filter on TPN tubing traps bacteria and particles but has no effect on nutrition. The nurse records intake and output to evaluate fluid replacement — not the nutritional adequacy of TPN.

The client has just undergone abdominal surgery and returned from the post-anesthesia care unit (PACU) with a patient-controlled analgesia (PCA) pump. Which interventions should the nurse implement? Select all that apply. Tell the client to push the button when in pain. Administer a bolus of pain medication. Change the patient-controlled analgesia (PCA) cartridge. Check the patient-controlled analgesia (PCA) settings with another nurse. Assess the IV insertion site.

Tell the client to push the button when in pain. Check the patient-controlled analgesia (PCA) settings with another nurse. Assess the IV insertion site. Explanation: The client is the only person who should push the PCA button and only when in pain. The settings should be checked with another nurse, ensuring the correct dosage is being administered. The PCA is intravenous and the site should be patent and free of erythema and infiltration.

A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide? "Apply one applicator of terconazole intravaginally at bedtime for 7 days." "Apply one applicator of tioconazole intravaginally at bedtime for 7 days." "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." "Apply sulconazole nitrate twice daily by massaging it gently into the lesions."

"Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." Explanation: A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours, six times per day for 7 days. Terconazole and tioconazole treat vulvovaginal candidiasis. Sulconazole nitrate treats tinea versicolor.

Allopurinol is prescribed for a client who has chronic gout. Which comment indicates that the client understands how to take the allopurinol? "I will take the medication whenever my joints hurt." "I must take this drug on an empty stomach." "I should drink plenty of fluids when taking allopurinol." "I should not take aspirin when taking allopurinol."

"I should drink plenty of fluids when taking allopurinol." Explanation: It is important that the client force fluids to 3,000 mL/day to avoid the development of renal calculi when taking allopurinol. Allopurinol must be taken consistently to be effective in the treatment of gout. The drug should be taken after meals to avoid gastrointestinal distress. Although the client can take aspirin when taking allopurinol, both drugs can cause gastrointestinal irritation, and the practice is not recommended if the client is sensitive to the medications.

A client has been taking dexamethasone for 2 weeks. The nurse evaluates a client's knowledge as deficient when the client says: "I cannot stop the dexamethasone all at one time." "If I forget a dose, it is no big deal; I will just take it when I remember it." "When I get a cold, I need to let my health care provider know." "I need to watch for an allergic reaction when I first start taking this pill."

"If I forget a dose, it is no big deal; I will just take it when I remember it." Explanation: The statement, "If I forget a dose, it is no big deal, I will just take it when I remember it," indicates a knowledge deficit. The nurse should reinforce that the client should take dexamethasone as prescribed and at the same time each day. The drug has to be tapered off and cannot be stopped abruptly. The health care provider (HCP) should be notified when the client is under additional stress (e.g., infection, surgery, illness). The client can have an allergic reaction to inactive ingredients contained in dexamethasone.

For a client with asthma, the health care provider (HCP) prescribes albuterol, two puffs twice a day via a metered-dose inhaler (MDI), and beclomethasone, two puffs twice a day via MDI. How should the nurse instruct the client to administer these drugs? "Take the medications 1 hour apart, two times a day." "Take the albuterol first and follow with beclomethasone two times a day." "Take the albuterol on awakening and alternate the medications every 4 hours." "Take the beclomethasone inhaler first and follow with albuterol."

"Take the albuterol first and follow with beclomethasone two times a day." Explanation: The nurse instructs the client to administer the bronchodilator first (the beta-2 agonist always leads) in order to open the airway and allow for improved delivery of the corticosteroid to the lung tissue, which follows after 1 minute between puffs. Using a spacer device with an MDI provides the best delivery of medication to the lungs.

A client with a urinary tract infection is to take nitrofurantoin four times each day. The client asks the nurse, "What should I do if I forget a dose?" What should the nurse tell the client? "You can wait and take the next dose when it's due." "Double the amount prescribed with your next dose." "Take the prescribed dose as soon as you remember it, and if it is very close to the time for the next dose, delay that next dose." "Tell your health care provider (HCP), who can then adjust your prescribed dose."

"Take the prescribed dose as soon as you remember it, and if it is very close to the time for the next dose, delay that next dose." Explanation: Antibiotics have the maximum effect when the level of the medication in the blood is maintained, and the client should take the medication as soon as possible after missing a dose. Because nitrofurantoin is readily absorbed from the gastrointestinal tract and is primarily excreted in urine, toxicity may develop by taking the dose too close to the time the next dose should be taken or doubling the dose. If possible, the client should not skip a dose, if one dose is missed. It is not necessary to contact the HCP as the dosage does not need to be adjusted. The nurse can coach the client to set a timer or use a pill container with timed doses so that the client does not forget to take the medication.

Dexamethasone (Decadron)

*class*: antiasthmatics, corticosteroids *Indication*:Manage cerebral edema, assess for Cushing's Disease *Action*: Suppress inflammation and normal immune response. Used in inflammatory states to decrease inflammation. *Nursing Considerations*: -Excreted by the liver - monitor liver profile - Avoid in active untreated infections - may cause CNS alterations - may cause peptic ulcers - may cause Cushingoid appearance (buffalo hump, moon face) - Weight gain - Osteoporosis - Decrease wound healing - May elevate blood sugars - May increase cholesterol and lipid values

A nurse is reviewing orders for a client having an acute asthma attack. Which of the following medications should the nurse administer? Albuterol 2.5 mg per nebulizer Methylprednisolone 60 mg IV Salmeterol 50 μg per dry-powder inhaler Triamcinolone two puffs per metered-dose inhaler

Albuterol 2.5 mg per nebulizer Explanation: Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications are used for long-term control of asthma and are not considered "rescue" inhalers since they are not immediate acting bronchodilators.

A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? Arrange for typing and crossmatching of the client's blood. Compare the client's identification wristband with the tag on the unit of blood. Start an I.V. infusion of normal saline solution. Measure the client's vital signs.

Arrange for typing and crossmatching of the client's blood. Explanation: The nurse should first arrange for typing and crossmatching of the client's blood to ensure compatibility with donor blood. Comparing the identification wristband with the tag on the blood, starting an I.V. infusion of normal saline solution, and measuring the client's vital signs, although appropriate when preparing to administer a blood transfusion, come later in the procedure.

A nurse preparing to administer a scheduled dose of phenytoin intravenous (IV) push verifies that the client has a patent venous access site in the right hand with an infusion of dextrose solution at a rate of 50 mL/hour. In addition to following the rights of medication administration, which of the following actions will the nurse take to give this drug safely? Select all that apply. Calculate the IV rate. Stop the IV infusion and flush with saline. Initiate a new IV site in the forearm. Dilute the drug with sterile water. Monitor for diarrhea.

Calculate the IV rate. Initiate a new IV site in the forearm. Dilute the drug with sterile water. Explanation: The rights of medication administration include giving the right drug and dosage to the right client at the right time through the right route. In addition, there are specific actions needed to safely administer certain medications. Phenytoin must be diluted in saline or sterile water because it will precipitate in dextrose solution. It will also cause hypotension and circulatory collapse if administered too quickly, thus a slow push rate is needed. Hand-vein access should be avoided to prevent discoloration.

A nurse should expect to administer which medication to a client with gout? Aspirin Furosemide Colchicine Calcium gluconate

Colchicine Explanation: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps; it doesn't treat gout.

The client with rapid-cycling bipolar disorder who is about to receive his 1700 hours dose of carbamazepine tells the nurse he has a sore throat and chills. What should the nurse do next? Administer the prescribed amount of carbamazepine. First, give the client acetaminophen as prescribed PRN. Report the symptoms to the health care provider (HCP) in the morning. Call the health care provider (HCP) immediately to report changes.

Call the health care provider (HCP) immediately to report changes. Explanation: The nurse should call the HCP to report symptoms of a sore throat, fever, and chills because these symptoms may be signs of serious adverse effects of the medication, including potentially fatal hematologic, cardiovascular, and hepatic complications. Giving the dose of carbamazepine is contraindicated in this situation. Giving the acetaminophen would be inappropriate and potentially detrimental to the client's health. Waiting until morning to report the client's symptoms is a serious error in judgment.

Teaching for women of childbearing years who are receiving antipsychotic medications includes which statement? This medication may result in heightened libido. Incidence of dysmenorrhea may increase while taking this drug. Continue previous contraceptive use even if you're experiencing amenorrhea. Amenorrhea is irreversible.

Continue previous contraceptive use even if you're experiencing amenorrhea. Explanation: Women may experience amenorrhea, which is reversible, while taking antipsychotics because amenorrhea doesn't indicate cessation of ovulation the client who experiences amenorrhea can still become pregnant. She should be instructed to continue contraceptive use even when experiencing amenorrhea. Dysmenorrhea isn't an adverse effect of antipsychotics, and the depressant effect generally decreases libido.

A client is receiving a blood transfusion, and 1 hour after starting the transfusion the client reports dyspnea and has crackles on lung auscultation. Which medication would be most important for the nurse to give? Acetaminophen 600 mg PO Furosemide 40 mg IV Diphenhydramine 50 mg PO Methylprednisolone 250 mg IV bolus

Furosemide 40 mg IV Explanation: This client is experiencing fluid overload usually noted after the first 15 minutes. The treatment of choice would be a diuretic. Acetaminophen would used to treat a febrile reaction; methylprednisolone and diphenhydramine would be indicated in an allergic reaction, which does not normally cause crackles

A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. Which action should the nurse take while administering oxygen in this manner? Humidify the air being delivered. Cover the neonate's scalp with a warm cap. Record the neonate's temperature every 3 to 4 minutes. Assess the neonate's blood glucose level.

Humidify the air being delivered. Explanation: Whenever oxygen is administered, it should be humidified to prevent drying of the nasal passages and mucous membranes. Because the neonate is under a radiant warmer, a stocking cap is not necessary. Temperature, continuously monitored by a skin probe attached to the radiant warmer, is recorded every 30 to 60 minutes initially. Although the oxygen concentration in the hood requires close monitoring and measurement of blood gases, checking the blood glucose level is not necessary.

The client comes to the healthcare provider reporting nasal discharge, malaise, headache, and a nonproductive cough. The healthcare provider orders guaifenesin for the client. What interventions should the nurse suggest with this medication? Select all that apply. Drink coffee. Use an inhaler. Increase fluid intake. Humidify the air. Take a laxative.

Increase fluid intake. Humidify the air. Explanation: The client should be told to increase fluid intake and add humidification because guaifenesin dries secretions. Drinking coffee, using inhalers, and taking a laxative are not part of the teaching regarding guaifenesin.

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product? Current guidelines suggest that no priming is needed since blood products must be infused alone Dextrose 5% in water as this is considered an isotonic solution Lactated Ringer's solution as this is considered an isotonic solution Normal saline solution as this is considered an isotonic solution

Normal saline solution as this is considered an isotonic solution Explanation: Normal saline solution is used for administering blood transfusions. Lactated Ringer's solution or dextrose solutions may cause blood clotting or RBC hemolysis. Current guidelines do not indicate a "no priming" method without NSS

A 30-year-old multiparous client has been prescribed oral contraceptives as a method of birth control. The nurse instructs the client that decreased effectiveness may occur if the client is prescribed which drug? indomethacin amitriptyline ampicillin omeprazole

ampicillin Explanation: Oral contraceptives may interact with other medications, and the effectiveness may be decreased if the client is prescribed ampicillin, tetracycline, or anticonvulsants, such as phenytoin. Indomethacin, an anti-inflammatory agent; amitriptyline, an antidepressant agent; and omeprazole, a drug used to suppress gastric acid secretion, do not decrease the effectiveness of oral contraceptives.

The client is in the postanesthesia care unit (PACU) recovering from surgery. The nurse administers the prescribed hydromorphone IV push (IVP). Five minutes later the nurse notes a respiratory rate of 9 breaths per minute on the same client. Which interventions should the nurse implement? Select all that apply. Start CPR. Ask the anesthesiologist to assess the client. Re-assess the client's respiratory rate in 5 minutes. Start ventilations. Administer naloxone.

Re-assess the client's respiratory rate in 5 minutes. Administer naloxone. Explanation: The nurse should administer naloxone and reassess every 5 minutes. The nurse should not wait for the anesthesiologist, the nurse should intervene immediately. CPR and ventilation's are not needed, the client is breathing and the heart is beating on its own.

The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose? Stimulation of peristalsis of the bowel. Reduced peripheral edema and ascites. Reduced serum ammonia levels. Prevention of hemorrhage.

Reduced serum ammonia levels. Explanation: Lactulose is used to treat hepatic encephalopathy by reducing serum ammonia levels. It is not used to stimulate bowel peristalsis, even though diarrhea can be a side effect of the drug. Lactulose does not have any effect on edema, ascites, or hemorrhage.

Why are antacids administered regularly, rather than as needed, in peptic ulcer disease? To keep gastric pH at 3.0 to 3.5 To promote client compliance To maintain a regular bowel pattern To increase pepsin activity

To keep gastric pH at 3.0 to 3.5 Explanation: To maintain a gastric pH of 3.0 to 3.5 throughout each 24-hour period, regular (not as needed) doses of an antacid are needed to treat peptic ulcer disease. Frequent administration of an antacid tends to decrease client compliance rather than promote it. Antacids don't regulate bowel patterns, and they decrease pepsin activity.

The most common reason given by mentally ill clients for noncompliance with medications is their uncomfortable adverse effects. When teaching the families, what need should the nurse identify as the greatest? alternative ways to manage the adverse effects home visits to set up a week's supply of medications family monitoring of the administration of medication outpatient monitoring of medication compliance

alternative ways to manage the adverse effects Explanation: Providing ways to decrease or manage adverse effects without additional medications is crucial. Although home visits, family monitoring, and outpatient monitoring may help, if the adverse effects are not controlled, the client is less likely to take the drug, which would interfere with its effectiveness.

Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? fluid balance anaphylactic reaction pain altered level of consciousness

anaphylactic reaction Explanation: The client who is receiving a blood product requires astute assessment for signs and symptoms of allergic reaction and anaphylaxis, including pruritus (itching), urticaria (hives), facial or glottal edema, and shortness of breath. If such a reaction occurs, the nurse should stop the transfusion immediately, but leave the IV line intact, and notify the health care provider. Usually, an antihistamine such as diphenhydramine hydrochloride) is administered. Epinephrine and corticosteroids may be administered in severe reactions. Fluid balance is not an immediate concern during the blood administration. The administration should not cause pain unless it is extravasating out of the vein, in which case the IV administration should be stopped. Administration of a unit of blood should not affect the level of consciousness.

A woman is taking oral contraceptives. The nurse teaches the client that medications that may interfere with oral contraceptive efficacy include: antihypertensives. antibiotics. diuretics. antihistamines.

antibiotics. Explanation: Broad-spectrum antibiotics can cause decreased efficacy of oral contraceptives, placing the client at risk for an unplanned pregnancy. When a client is prescribed a course of antibiotics, a back-up method of contraception should be used. Antihypertensives, diuretics, and antihistamines do not interfere with oral contraceptive efficacy.

Which over-the-counter medications should the nurse tell the mother of a child with hemophilia to avoid using? aspirin magnesium hydroxide acetaminophen multivitamin capsules

aspirin Explanation: Aspirin inhibits platelet aggregation, prolongs bleeding time, and inhibits prothrombin synthesis. It is, therefore, contraindicated for a child with hemophilia. Acetaminophen is the recommended alternative for analgesic and antipyretic purposes. Magnesium hydroxide and multivitamin capsules have no effect on bleeding and are not contraindicated for a child with hemophilia.

The nurse has given a client a nitroglycerin tablet sublingually for angina. Which vital signs should be assessed following administration of nitroglycerin? pulse rate oxygen saturation respiratory rate blood pressure

blood pressure Explanation: Nitroglycerin can cause hypotension. A priority nursing assessment after the administration of nitroglycerin is the client's blood pressure. Oxygen saturation, respiratory rate, and pulse rate are not priority nursing assessments after the administration of nitroglycerin.

A client with benign prostatic hypertrophy (BPH) is being treated with terazosin 2 mg at bedtime. What should the nurse tell the client to monitor on a regular basis? glucosuria glucose restlessness blood pressure pulse

blood pressure Explanation: Terazosin is an antihypertensive drug that is also used in the treatment of BPH. The client should monitor his blood pressure to ensure he does not develop hypotension, syncope, or orthostatic hypotension. The client should be instructed to change positions slowly. Terazosin does not cause glycosuria, restlessness, or changes in the heart rate.

A toddler with a ventricular septal defect is receiving digoxin to treat heart failure. Which assessment finding should be the nurse's priority concern? bradycardia tachycardia hypertension hyperactivity

bradycardia Explanation: Digoxin enhances cardiac efficiency by increasing the force of contraction and decreasing the heart rate. An early sign of digoxin toxicity is bradycardia (an abnormally slow heart rate). To help detect digoxin toxicity, the nurse always should measure the apical heart rate before administering each digoxin dose. Other signs and symptoms of digoxin toxicity include arrhythmias, vomiting, hypotension, fatigue, drowsiness, and visual halos around objects. Tachycardia, hypertension, and hyperactivity aren't associated with digoxin toxicity.

Which adverse effect occurs when there is too rapid an infusion of TPN solution? negative nitrogen balance circulatory overload hypoglycemia hypokalemia

circulatory overload Explanation: Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is administered too rapidly, the client is at risk for receiving an excess of dextrose and electrolytes. Therefore, the client is at risk for hyperglycemia and hyperkalemia.

A client with cholecystitis is taking propantheline bromide. The expected outcome of this drug is: increased bile production. decreased biliary spasm. absence of infection. relief from nausea.

decreased biliary spasm. Explanation: Propantheline bromide is an anticholinergic used to decrease biliary spasm. Decreasing biliary spasm helps to reduce pain in cholecystitis. Propantheline does not increase bile production or have an antiemetic effect, and it is not effective in treating infection.

A 28-year-old female client is prescribed danazol for endometriosis. The nurse should instruct the client to report: headaches. weight loss. increased libido. hair loss.

headaches. Explanation: Adverse effects of danazol include headaches, dizziness, irritability, and decreased libido. Masculinization effects, such as deepened voice, facial hair, and weight gain, also may occur.

Methylphenidate hydrochloride has been prescribed for a child with attention deficit hyperactivity disorder. The nurse should make which of the following statements to the child's parents? Select all that apply. "You will see a positive response to methylphenidate hydrochloride in approximately 8 weeks." "You should give the dose to your child right before his evening bedtime." "Extended-release tablets may be crushed or chewed." "If discontinued, methylphenidate hydrochloride must be tapered off slowly." "If the symptoms do not improve, the medication may need to be adjusted."

"If discontinued, methylphenidate hydrochloride must be tapered off slowly." "If the symptoms do not improve, the medication may need to be adjusted." Explanation: Methylphenidate hydrochloride must never be stopped abruptly and requires tapering of the dosage as directed by a physician. Parents who see an improvement in the child may believe the child no longer needs to take the medication, so this information is very important. Parents should be aware to contact the physician if symptoms are not improving on the medication. Extended release tablets are never crushed or chewed, and children generally take their dosage in the morning.

A client is taking lithium carbonate. The client asks for explanations of why regular blood tests are needed. The nurse explains that it is to detect lithium toxicity. Which of the following statements, if made by the client, indicates to the nurse that the teaching about lithium toxicity has been effective? "There may be too much medication in my bloodstream." "This blood test tells the doctor if the medication is effective." "I should get my blood checked if I don't feel well." "Blood tests will prevent common side effects of taking the medication."

"There may be too much medication in my bloodstream." Explanation: Lithium has a very narrow range between the therapeutic range and the toxic level. Toxicity describes the systemic effects of the medication when there is an excess of medication in the bloodstream. The level at which the medication is most effective (therapeutic level) is the desired state of having the correct amount of medication in the bloodstream. Having a lithium level drawn will not prevent common side effects. The client should still get blood level drawn even if he/she feels well and is not having side effects. A therapeutic level is more likely to have positive effects on bipolar disorder. The level is individualized for each client, and effectiveness should be determined by penetrance of symptoms.

Which statement by a client who has been taking buspirone as prescribed for 2 days indicates the need for further teaching? "This medication will help my tight, aching muscles." "I may not feel better for 7 to 10 days." "The drug does not cause physical dependence." "I can take the medication with food."

"This medication will help my tight, aching muscles." Explanation: Buspirone, a nonbenzodiazepine anxiolytic, is particularly effective in treating the cognitive symptoms of anxiety, such as worry, apprehension, difficulty with concentration, and irritability. Buspirone is not effective for the somatic symptoms of anxiety (muscle tension). Therapeutic effects may be experienced in 7 to 10 days, with full effects occurring in 3 to 4 weeks. This drug is not known to cause physical or psychological dependence. It can be taken with food or small meals to reduce gastrointestinal upset.

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem? A hemolytic reaction to mismatched blood A hemolytic reaction to Rh-incompatible blood A hemolytic allergic reaction caused by an antigen reaction A hemolytic reaction caused by bacterial contamination of donor blood

A hemolytic allergic reaction caused by an antigen reaction Explanation: Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnea, chest pain, hypotension, and other signs of anaphylaxis a few minutes after blood transfusion begins. Although rare, a hemolytic reaction to mismatched blood can occur, triggering a more severe reaction and, possibly, leading to disseminated intravascular coagulation. A hemolytic reaction to Rh-incompatible blood is less severe and occurs several days to 2 weeks after the transfusion. Bacterial contamination of donor blood causes a high fever, nausea, vomiting, diarrhea, abdominal cramps and, possibly, shock.

A client diagnosed with major depression has started taking amitriptyline hydrochloride, a tricyclic antidepressant. What is a common adverse effect of this drug? Weight loss Dry mouth Hypertension Muscle spasms

Dry mouth Explanation: Tricyclic antidepressants can have anticholinergic adverse effects, with dry mouth being the most common. Hypotension would be expected, rather than hypertension. Weight gain — not loss — is typical when taking this medication. Muscle spasms aren't an adverse effect of tricyclic antidepressants.

A nurse is reviewing the health care provider's orders for a client admitted with systemic lupus erythematosus (SLE). Which medication would the nurse expect to find in this client's plan of care? Morphine Ketoconazole Hydroxychloroquine Dimenhydrinate

Hydroxychloroquine Explanation: Fatigue, photosensitivity and a "butterfly" rash on the face are all signs and symptoms of SLE. Hydroxychloroquine is used in the treatment of SLE to prevent inflammation. Pharmacological treatment of SLE also involves nonsteroidal anti-inflammatory drugs, corticosteroids, and immunosuppressive agents. Morphine is an opioid analgesic, ketoconazole is an antifungal agent, and dimenhydrinate is an antiemetic.

What is the nurse's priority action when administering phenytoin to a client intravenously? Administer rapidly Withhold other anticonvulsants Mix phenytoin with saline solution only Use only dextrose solution when flushing the IV catheter

Mix phenytoin with saline solution only Explanation: Phenytoin is only compatible with saline solutions. Dextrose will cause an insoluble precipitate to form. Phenytoin should be administered at a rate of less than 50 mg/min. There is no need to withhold additional anticonvulsants.

A nurse in a psychiatric inpatient unit is caring for a client with generalized anxiety disorder. As part of the client's treatment, the psychiatrist orders lorazepam, 1 mg by mouth three times per day. During lorazepam therapy, the nurse should remind the client to: avoid caffeine. avoid aged cheeses. stay out of the sun. maintain an adequate salt intake.

avoid caffeine. Explanation: Ingesting 500 mg or more of caffeine can significantly alter the anxiolytic effects of lorazepam. Other dietary restrictions are unnecessary. Staying out of the sun or using sunscreens is required when taking phenothiazines. An adequate salt intake is necessary for clients receiving lithium.

Which performance improvement strategy helps prevent adverse reactions to blood products? Confirming client identification with two qualified health professionals Obtaining baseline vital signs Instructing the client about the signs and symptoms of a blood reaction Priming the blood administration tubing with normal saline solution

Confirming client identification with two qualified health professionals Explanation: The client must be correctly identified to prevent a life-threatening adverse blood reaction. Obtaining vital signs, instructing the client about the signs and symptoms of a blood reaction, and priming the blood administration tubing with normal saline solution are key steps in the blood administration procedure; however, they don't prevent adverse reactions.

Lorazepam is commonly given along with a neuroleptic agent. What is the purpose of administering the drugs together? To reduce anxiety and potentiate the neuroleptic's sedative action To counteract the neuroleptic's extrapyramidal effects To manage depressed clients To increase a client's level of awareness and concentration

To reduce anxiety and potentiate the neuroleptic's sedative action Explanation: Lorazepam, when taken with a neuroleptic such as haloperidol, potentiates the neuroleptic's sedating effect and is used to treat severely agitated clients. Lorazepam wouldn't be given to counteract extrapyramidal effects. Both drugs can cause depression, so they aren't used to treat depression. The drugs' depressant effect would decrease concentration, not increase it.

A client with chest pain doesn't respond to nitroglycerin. When he's admitted to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms? Within 6 hours Within 12 hours Within 24 to 48 hours Within 5 to 7 days

Within 6 hours Explanation: For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Physicians initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.

A client has received an overdose of sympathomimetic agents. The nurse should assess the client for which late signs of an overdose? Select all that apply. hypotension bradycardia seizures profound pyrexia hypertension

hypotension seizures profound pyrexia Explanation: As the homeostatic responses begin to decompensate, late clinical manifestations from a large overdose of sympathomimetic agents include loss of function of the hypothalamus such as temperature regulation, leading to profound pyrexia, and ectopic brain activity leading to seizures. Hypotension is a late sign that occurs as the vascular system collapses. Hypertension, an earlier sign, precedes hypotension. Tachycardia occurs as a reflex to hypotension, a late sign.

In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? oral analgesics such as ibuprofen or acetaminophen intravenous opioids intramuscular opioids oral antianxiety agents such as lorazepam

intravenous opioids Explanation: The severe pain experienced by burn clients requires opioid analgesics. In addition, opioids such as morphine sedate and alleviate apprehension. Oral analgesics such as ibuprofen or acetaminophen are unlikely to be strong enough to effectively manage the intense pain experienced by the client who is severely burned. Because of the altered tissue perfusion from the burn injury, intravenous medications are preferred. Antianxiety agents are not effective against pain.

The client, who is taking fluoxetine 20 mg at bedtime, tell the nurse the drug is interfering with his sleep. The nurse should conclude that: the client should take fluoxetine in the morning. the dosage is too high. the client's symptoms of depression seem to be getting worse. the client is on the wrong medication.

the client should take fluoxetine in the morning. Explanation: Fluoxetine should be taken as early in the day as possible so as not to interfere with nighttime sleep; it may cause nervousness in some clients. The dosage is therapeutic and not too high. There is no evidence in this situation to justify the conclusion that the client's depression is worsening or that the client is on the wrong medication.

Which statement indicates that the client needs further teaching about taking medication to control cancer pain? "I should take my medication around-the-clock to control my pain." "I should skip doses periodically so I do not get hooked on my drugs." "It is okay to take my pain medication even if I am not having any pain." "I should contact the oncology nurse if my pain is not effectively controlled."

I should skip doses periodically so I do not get hooked on my drugs." Explanation: The client should not skip his dosages of pain medication to prevent addiction. Clients with cancer pain do not become psychologically dependent on the medication and should not fear becoming addicted. The nurse should allow the client and family members to verbalize their concerns about drug addiction.

The nurse observes a new parent give an oral medication to their 4-month-old infant. The parent instills the medication directly in the back of the infant's throat. Which of the following is the nurse's best action? Instruct the parent to instill a small amount of the medication inside the baby's cheek Praise the parent's technique of giving the medication Have the parent lay the infant flat, restraining the arms, while giving the medication Demonstrate to the parent ways to prop the infant in a sitting position for medication administration

Instruct the parent to instill a small amount of the medication inside the baby's cheek Explanation: The parent's technique of instilling the medication in the back of the throat is not correct and could cause the infant to choke. The nurse should instruct the parents to instill a small amount at a time inside the infant's cheek. The parent should hold an infant in the bottle-feeding position when administering an oral medication by placing the child's inner arm behind the back, supporting the head in the crook of the elbow, and holding the child's free hand with the hand of the supporting arm. Propping a 4-month-old infant is not appropriate. The infant cannot sit unsupported even in a seated position. Administering medication to an infant lying flat could cause choking and aspiration.

During the intravenous administration of a chemotherapeutic vesicant drug, the nurse observes that there is a lack of blood return from the intravenous catheter. What should the nurse do first? Stop the administration of the drug. Reposition the client's arm and continue with administration of the drug. Irrigate the catheter with normal saline. Continue to administer the drug and assess for edema at the IV site.

Stop the administration of the drug. Explanation: An intravenous catheter with no blood return is most likely occluded and not patent. A chemotherapeutic vesicant drug extravasates into the surrounding skin tissue and causes tissue necrosis. The nurse stops administration of the drug immediately. Repositioning the arm does not improve patency. Irrigating the catheter may cause the medication to enter tissue. It is inappropriate to wait and see if the arm becomes edematous because of the vesicant action of the drug.

The nurse assesses a client who is receiving a tube feeding. Which situation would require prompt intervention from the nurse? The client is sitting upright in bed while the feeding is infusing. The feeding that is infusing has been hanging for 8 hours. The client has a gastric residual of 25 mL. The feeding solution is at room temperature.

The feeding that is infusing has been hanging for 8 hours. Explanation: Feeding solutions that have not been infused after hanging for 8 hours should be discarded because of the increased risk of bacterial growth. Sitting the client upright during the feeding helps prevent aspiration of the feeding. A gastric residual of 25 mL is considered acceptable. A gastric residual of 100 to 150 mL, or a residual greater than 100% of the previous hour's intake, indicates delayed emptying. The feeding solution should be at room or body temperature.

When evaluating teaching a client how to administer insulin, which action indicates that additional teaching is necessary? The client: draws up the regular insulin first and then the NPH. rotates sites from legs to arms. identifies that the syringe is U-100 waits 30 minutes to eat breakfast after injecting rapid-acting insulin

waits 30 minutes to eat breakfast after injecting rapid-acting insulin Explanation: The nurse instructs the client to not wait any longer than 5 to 15 minutes to eat after injecting rapid-acting insulin, which has an onset action of 5 minutes and duration of 1 hour. The client is using proper technique for mixing the insulins, rotating sites, and using the U-100 syringe.

Five days after running out of medication, a client taking clonazepam tells the nurse, "I know I shouldn't have just stopped the drug like that, but I'm OK." What is the nurse's most appropriate response? "Let's monitor you for problems, in case something else happens." "You could go through withdrawal symptoms for up to two weeks." "You have handled your anxiety, and now you know how to cope with stress." "If you're fine now, chances are you won't experience withdrawal symptoms.

"You could go through withdrawal symptoms for up to two weeks." Explanation: Withdrawal symptoms can appear after one or two weeks because the benzodiazepine has a long half-life. Looking for another problem unrelated to withdrawal isn't the nurse's best strategy. The act of discontinuing an antianxiety medication doesn't indicate that a client has learned to cope with stress. Every client taking medication needs to be monitored for withdrawal symptoms when the medication is abruptly stopped.

What is the most important information for the nurse to include when teaching a client about metronidazol? Breathlessness and cough are common adverse effects. Urine may develop a greenish tinge while the client is taking this drug. Mixing this drug with alcohol causes severe nausea and vomiting. Heart palpitations may occur and should be immediately reported.

Mixing this drug with alcohol causes severe nausea and vomiting. Explanation: When mixed with alcohol, metronidazole causes a disulfiram-like effect involving nausea, vomiting, and other unpleasant symptoms. Urine may turn reddish brown, not greenish, from the drug. Cardiovascular or respiratory effects are not associated with this drug.

The student nurse is planning to care for an intravenous (IV) site for a client receiving chemotherapy. Which of the following outcomes would demonstrate that the student understands the concepts of IV care? Clean the insertion site and change the dressing within 24 to 72 hours. Periodically flush the catheter with heparin to maintain its flow of IV solution. Monitor for redness, drainage, and swelling at the insertion site once every 24 hours. Rotate the insertion site every 72 hours.

Rotate the insertion site every 72 hours. Explanation: Venous access devices are commonly used for clients receiving long-term chemotherapy, total parenteral nutrition, or frequent medication or fluids. These devices may remain in place for several weeks to more than 1 year if no complications develop. Based on best practice, all other answers do not meet the criteria for care. The site could be cleaned and dressing changed more often than 24-72 hours; this does not address potential insertion site infection. Heparin is not used for peripheral sites. Nurses monitor IV sites more frequently than once every 72 hours.

Modafinil has been ordered for a client diagnosed with narcolepsy. The nurse understands that this medication: is an antianxiety agent. is a central nervous system (CNS) depressant. promotes wakefulness. is a mood stabilizer.

promotes wakefulness. Explanation: Although modafinil's mechanism of action isn't fully known, this drug promotes wakefulness. It's indicated for treatment of individuals with narcolepsy, obstructive sleep apnea, or shift work type sleep-wake disorder. It would increase anxiety and elevate mood. CNS depressants and antianxiety agents would worsen the symptoms of narcolepsy. Mood stabilizers aren't indicated for narcolepsy.

The nurse is working in an internal medicine office. A daughter brings her older adult mother to the health care provider's appointment. Upon reviewing the medication list, the daughter states, "Which medication is prescribed to prevent a stroke?" The nurse is correct to answer which medication? allopurinol loratadine ticlopidine methylprednisolone

ticlopidine Explanation: Ticlopidine inhibits platelet aggregation by interfering with adenosine diphosphate release in the coagulation cascade and, therefore, is used to prevent thromboembolic stroke. Allopurinol is an antigout medication used to reduce uric acid. Loratadine is an over-the-counter allergy medication. Methylprednisolone, a steroid with anticoagulant properties, is not used to treat thromboembolic stroke.

A client is taking vancomycin. The nurse should report which possible side effect to the health care provider (HCP)? vertigo tinnitus muscle stiffness ataxia

tinnitus Explanation: The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated with vancomycin.

The nurse teaches the client with cirrhosis that the expected outcome of taking lactulose is: one regular bowel movement a day. two to three soft stools per day. four to five loose stools per day. five to six loose stools per day.

two to three soft stools per day. Explanation: The expected effect of lactulose is for the client to have two to three soft stools a day to help reduce the pH and serum ammonia levels, which will prevent hepatic encephalopathy.

Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate? urine output greater than 30 ml/hour systolic blood pressure greater than 110 mm Hg diastolic blood pressure greater than 90 mm Hg respiratory rate of 20 breaths/minute

urine output greater than 30 ml/hour Explanation: Urine output provides the most sensitive indication of the client's response to therapy for hypovolemic shock. Urine output should be consistently greater than 35 mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock.

As an initial step in treating a client with angina, the health care provider (HCP) prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: antispasmodic effects on the pericardium. causing an increased myocardial oxygen demand. vasodilation of peripheral vasculature. improved conductivity in the myocardium.

vasodilation of peripheral vasculature. Explanation: Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

The health care provider (HCP) has prescribed insulin detemir for a client with type 2 diabetes requiring insulin. What should the nurse teach the client about this insulin? "You may increase the carbohydrates in your diet when using this insulin." "You do not need to rotate injection sites with this insulin." "You do not mix insulin detemir; the solution is clear." "You may refill the detemir insulin pen."

"You do not mix insulin detemir; the solution is clear." Explanation: Insulin detemir is used only if the solution appears clear and colorless with no visible particles. Insulin detemir is not diluted or mixed with any other insulin preparations. As with any insulin therapy, lipodystrophy may occur at the injection site and delay insulin absorption. Continuous rotation of the injection site within a given area may help to reduce or prevent this reaction. The client should continue to follow the prescribed diet and monitor glucose levels when taking insulin detemir. Insulin detemir is available in a prefilled insulin pen. When the insulin pen is empty, it may not be refilled; instead the pen is discarded.

A client is admitted to the local psychiatric facility with bipolar disorder in the manic phase. The physician decides to start the client on lithium carbonate therapy. One week after this therapy starts, the nurse notes that the client's serum lithium level is 1 mEq/L. What should the nurse do? Call the physician immediately to report the laboratory result. Observe the client closely for signs and symptoms of lithium toxicity. Withhold the next dose and repeat the laboratory test. Continue to administer the medication as ordered.

Continue to administer the medication as ordered. Explanation: The serum lithium level should be maintained between 1 and 1.4 mEq/L during the acute manic phase; therefore, the nurse should continue to administer the medication as ordered. Unless the client has signs or symptoms of lithium toxicity, the nurse has no need to call the physician, withhold the medication, or repeat the laboratory test. Nonetheless, the nurse should continue to monitor the client's serum lithium level and watch for indications of toxicity if the level begins to rise. Note that it's possible for a client with a normal lithium level to experience lithium toxicity.

The nurse is reconstituting a powdered medication in a vial. After adding the solution to the powder, the nurse should: stir the liquid with a sterile applicator. invert the vial and let it stand for 2 to 3 minutes. shake the vial vigorously. roll the vial gently between her palms.

roll the vial gently between her palms. Explanation: Rolling the vial gently between the palms produces heat, which helps dissolve the medication. Stirring the medication with a sterile applicator isn't accepted practice. Inverting the vial wouldn't help dissolve the medication. Shaking the vial vigorously could cause the medication to break down, altering its action.

Which instruction is most important for the nurse to include in the teaching plan for a client who is taking phenelzine? Eat a normal amount of salt in the diet. Drink 10 to 12 glasses of water each day. Allow 10 days to achieve therapeutic effects. Avoid foods high in tyramine.

Avoid foods high in tyramine. Explanation: A client who is taking phenelzine, a monoamine oxidase inhibitor, needs to avoid foods that are rich in tyramine because this food-drug combination can cause hypertensive crisis. The client should be given a list of foods to avoid and should report headaches, palpitations, and a stiff neck to the health care provider (HCP) immediately. The client does not need to restrict or add salt to the diet. Drinking 10 to 12 glasses of water each day is important to teach the client who is receiving lithium therapy. Antidepressant drugs take 2 to 4 weeks to achieve therapeutic effects.

A client is brought to the ED with narcotic overdose and respiratory depression. The client is administered naloxone hydrochloride, and then asks the nurse, "What if I am allergic to what you gave me?" What adverse effects should the nurse communicate to the client? Select all that apply. seizures tachycardia tremors decreased urine output hypoventilation

tachycardia tremors Explanation: Adverse effects of naloxone hydrochloride include tachycardia, hyperventilation, and tremors. Adverse effects of opioids include seizures, hypoventilation, and decreased urine output.

The nurse instructs a client who is taking iron supplements that: iron supplements should be taken on an empty stomach. a daily bulk laxative such as psyllium hydrophilic mucilloid should be avoided. the stools will become darker. liquid iron supplements will not discolor teeth.

the stools will become darker. Explanation: Iron supplements will darken the stools. Iron supplements should not be taken on an empty stomach because they can cause gastric irritation. Iron is constipating, and a daily bulk-forming laxative should be started prophylactically. A straw should be used when taking liquid iron to avoid discoloring the teeth.

After sustaining a closed head injury, a client is prescribed phenytoin 100 mg intravenously every 8 hours for seizure prophylaxis. Which nursing interventions are necessary when administering phenytoin? Select all that apply. Administer phenytoin slowly, diluted in 250 cc. Mix intravenous doses in solutions containing dextrose 5% in water. Administer an intravenous bolus no faster than 50 mg/minute. Monitor electrocardiogram (ECG), blood pressure, and respiratory status continuously when administering phenytoin intravenous. Do not use an in-line filter when administering the drug. Monitor the client for signs of early toxicity, such as drowsiness, nystagmus, ataxia, dysarthria, tremor, and slurred speech.

Administer an intravenous bolus no faster than 50 mg/minute. Monitor electrocardiogram (ECG), blood pressure, and respiratory status continuously when administering phenytoin intravenous. Monitor the client for signs of early toxicity, such as drowsiness, nystagmus, ataxia, dysarthria, tremor, and slurred speech. Explanation: Administer an intravenous bolus by slow (50 mg/minute) intravenous push method; too rapid an injection may cause hypotension and circulatory collapse. Continuous monitoring of ECG, blood pressure, and respiratory status is essential when administering phenytoin intravenously. A dilution of 250 cc is not required. Early toxicity may cause drowsiness, nausea, vomiting, nystagmus, ataxia, dysarthria, tremor, and slurred speech. Later effects may include hypotension, arrhythmias, respiratory depression, and coma. Death may result from respiratory and circulatory depression. Phenytoin would not be administered by intravenous push in veins on the back of the hand; larger veins are needed to prevent discoloration associated with purple glove syndrome. Mix intravenous doses in normal saline solution and use the solution within 30 minutes; doses mixed in dextrose 5% in water will precipitate. Use of an inline filter is recommended.

A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus? Gently aspirate the I.V. catheter to check for a blood return. Insert a second I.V. line into the opposite arm. Warm the I.V. medication to room temperature. Place a tourniquet on the arm in which she will administer the injection.

Gently aspirate the I.V. catheter to check for a blood return. Explanation: Before administering an I.V. bolus, the nurse should gently aspirate the I.V. catheter for a small amount of blood to ensure correct placement of the I.V. catheter. Then the nurse may inject the medication over the recommended time interval. She doesn't need to insert another I.V. line unless the ordered medication is incompatible with the medication in the I.V. solution. Warming the medication could alter the drug's action. Placing a tourniquet on the arm would close off the venous system and prevent drug injection.

After the nurse teaches a client and family about lithium therapy, which client statements indicates the need for further teaching? "I need to eliminate salt in my diet." "I should drink 10 to 12 glasses of water daily." "I should avoid driving until I am stabilized." "I will report any vomiting, diarrhea, blurred vision, or weakness."

"I need to eliminate salt in my diet." Explanation: Clients receiving lithium need to have a consistent dietary intake of sodium to maintain a therapeutic serum lithium level of 0.6 to 1.2. A decrease in salt intake decreases lithium elimination, causing an increase in the serum lithium level. The client who is taking lithium needs to ingest adequate amounts of fluid, from 2,400 to 3,000 mL per day. Drinking 10 to 12 glasses of water each day would aid in achieving this goal. Because drowsiness and dizziness can occur with this drug, the client should avoid driving until the effects of the drug are known and the client is stabilized. Calling the healthcare provider if vomiting, diarrhea, blurred vision, or weakness occurs is important because these symptoms may indicate lithium toxicity.

Which of the following techniques is correct when administering a subcutaneous injection? Use a 1-inch (2.5-cm) needle for injection. Insert the needle at a 45-degree angle to the skin. Spread the skin tightly at the injection site. Draw 0.2 ml of air into the syringe before administration.

Insert the needle at a 45-degree angle to the skin. Explanation: Subcutaneous injections are administered at an angle of 45 to 90 degrees, depending on the size of the client. Subcutaneous needles are typically to 1/2 to 5/8 inches (1.3 to 1.6 cm) in length. The skin should be pinched up at the injection site to elevate the subcutaneous tissue. Air is not drawn into the syringe for a subcutaneous injection.

A client has been taking furosemide for 2 days. The nurse should assess the client for: an elevated blood urea nitrogen (BUN) level. an elevated potassium level. a decreased potassium level. an elevated sodium level.

a decreased potassium level. Explanation: Furosemide is a loop diuretic and inhibits the reabsorption of sodium and chloride from the proximal and distal renal tubules and the loop of Henle. Furosemide promotes sodium diuresis, resulting in a loss of potassium and serious electrolyte imbalances. Furosemide does not affect the BUN level.

Hydrocodone with acetaminophen has been prescribed for a client with metastatic prostate cancer. What information is essential for the nurse to include in the teaching plan? "You may develop blurred vision." "Constipation may develop with constant use." "You may feel more relaxed and calm." "Nausea may occur."

"Constipation may develop with constant use." Explanation: Constipation commonly develops with constant use of hydrocodone. The nurse should teach the client about constipation, and tell the client ways to decrease this risk, such as increasing fiber and liquids in the diet. Nausea may occur on occasion, however, it is not a severe problem, and could be related to constipation. Blurred vision and diarrhea are not associated with the use of hydrocodone with acetaminophen. Feeling relaxed and calm is a common side effect does not need medical attention. As the body adjusts to the medicine during treatment these side effects may go away.

The client was found not breathing and was transported to the hospital. A family member states the client may have taken too much pain medication because the client frequently forgets if the medication was taken. Which observation(s) by the nurse indicates therapeutic effect of naloxone hydrochloride in the client? Select all that apply. Reverses decreased respiratory rate of 10. Reverses decreased level of consciousness. Increases nerve pain. Reverses blood pressure of 90/58. Increases inflammation.

Reverses decreased respiratory rate of 10. Reverses decreased level of consciousness. Reverses blood pressure of 90/58. Explanation: Therapeutic effect includes reversal of respiratory depression, sedation, and hypotension. Therapeutic effect does not include increasing nerve pain or increasing inflammation.