module 8 questions

Carmela has been receiving furosemide 40 mg/day. Which laboratory results indicate an adverse effect? Select all that apply. Hypokalemia Hypouricemia Hypoglycemia Hypernatremia Hypermagnesemia Increased blood urea nitrogen (BUN)

Hypokalemia, Increased BUN RATIONALE: Furosemide is a loop diuretic that enhances excretion of sodium, chloride, and potassium by way of direct action at the ascending limb of the loop of Henle. Loop diuretics may cause marked depletion of water and electrolytes (potassium and sodium, as well as calcium, chloride, and magnesium); they may cause increases in the levels of blood glucose, uric acid, and BUN.

Which side/adverse effect of captopril will the nurse monitor for in Carmela? Weight gain Bradycardia Hypotension Hypokalemia

Hypotension RATIONALE: Captopril is an angiotensin-converting enzyme (ACE) inhibitor. The main side/adverse effects of this medication are cough, hypotension, hyperkalemia, and tachycardia. Other side effects associated with ACE inhibitors include headache, dizziness, fatigue, insomnia, and weight loss.

While reviewing the results of Helena's laboratory studies, the nurse notes that Helena's hemoglobin is 6.8 g/dL (68 mmol/L) and her hematocrit is 24%. The nurse reports the results to the health care provider, who prescribes a transfusion of 1 unit of packed red blood cells (RBCs). Which are part of the correct procedures for administering the blood? Select all that apply. Using a 22-gauge needle to infuse the blood Monitoring Helena for circulatory overload during the infusion Planning to ensure that the infusion will be complete in 4 hours Monitoring Helena closely for a transfusion reaction, especially during the first 50 mL of the transfusion Ensuring that the transfusion is started within 1 hour of the blood bag's delivery to the nursing unit from the blood bank.

Monitoring Helena for circulatory overload during the infusion Planning to ensure that the infusion will be complete in 4 hours Monitoring Helena closely for a transfusion reaction, especially during the first 50 mL of the transfusion

The venipuncture site has been cared for, and Josephine is resting comfortably. Twenty-four hours after Josephine's admission to the medical unit, the health care provider increases the flow rate of the IV solution to 100 mL/hr because Josephine continues to experience episodes of diarrhea and is still exhibiting signs of dehydration. Which actions should the nurse take to monitor Josephine for complications after increasing the flow rate? Select all that apply. Monitoring Josephine's weight Watching for slow, shallow breathing Auscultating for crackles in the lungs Assessing Josephine for flat jugular veins Monitoring blood pressure to detect hypertension Monitoring intake and output for increasing urine output

Monitoring Josephine's weight Auscultating for crackles in the lungs Monitoring blood pressure to detect hypertension Circulatory overload may result from the too-rapid administration of fluids; it may also occur in a client already at risk for fluid overload (e.g., older and very young clients and clients with respiratory, cardiovascular, liver, and renal disorders). Signs include increased blood pressure, distended jugular veins, tachypnea, dyspnea, moist cough, and crackles on auscultation of the lungs. The weight will also increase with overloaded fluid volume. The increasing urine output is a sign of improved dehydration, not a complication of increased fluid. If circulatory overload occurs, the nurse slows the IV flow rate to a keep-vein-open rate, elevates the head of the bed, keeps the client warm, assesses the client for pulmonary edema, and notifies the health care provider.

The nurse administers the IV diphenhydramine hydrochloride to Helena and begins the blood transfusion. After 15 minutes, Helena has shown no signs of a reaction and her vital signs are stable. The nurse increases the flow rate of the infusion and notes that the blood is infusing more slowly than the set rate. The nurse prepares to dilute the blood per agency policy. Which intravenous (IV) solution is essential for the nurse to select for dilution? 5% dextrose in water Normal saline solution Lactated Ringer's solution 5% dextrose in 0.45% normal saline solution

Normal saline solution Normal saline solution is the only solution that can be used to dilute blood. Any other solution will cause hemolysis; therefore 5% dextrose in water, lactated Ringer's solution, and 5% dextrose in 0.45% normal saline solution are all incorrect choices.

The registered nurse is a case manager for the emergency department. A client is brought to the emergency department by emergency medical services after sustaining a gunshot wound to the abdomen. The client, bleeding profusely, requires an immediate transfusion of whole blood, but his blood type is unknown. When conducting a case review, the case manager determines appropriate action was taken if which type of blood was requested from the blood bank? O-positive O-negative AB-positive AB-negative

O-negative Whole blood is used in the event of major blood loss. Typing and crossmatching are normally performed to identify the client's blood type (A, B, AB, O), to check for the presence of the Rh factor, and to ensure compatibility with the donor's blood. In an extreme emergency, however, the client may be transfused with O-negative blood, which is considered the "universal" donor blood type. AB-positive is the universal recipient type — a client with this blood type may be given any of the types of blood safely.

Josephine's condition has improved. Josephine has not had any episodes of vomiting or diarrhea for 24 hours and is still receiving an IV infusion, but she is tolerating the intake of oral fluids. The health care provider writes an order discontinuing the IV fluid infusion and prescribes a saline lock until discharge tomorrow. Which actions by the nurse are essential in completing this prescription? Select all that apply. Washing the hands Informing the client Labeling the tubing Inserting the IV catheter Checking the client's vital signs Flushing the lock with NS per agency policy

Washing the hands Informing the client Flushing the lock with NS per agency policy the hands must be washed before the nurse works with an IV site; gloves are worn because bleeding may occur. The change of the IV site to a saline lock must be explained to the client and family so they are aware of what the nurse is doing. The saline lock is flushed with NS to keep it open and available for use, should the need arise. Locking may simply involve the addition of a cap to the IV catheter hub, or a loop of extension tubing may be added between the catheter hub and the cap for injection if the IV site is not easy to reach or if it is the agency's policy. It is not necessary to label the extension tubing, because it will be changed when the IV catheter is changed. A new IV catheter does not need to be inserted if the IV site already exists and is still functioning well. The vital signs will be monitored, but this is not essential in changing an IV site to a saline lock.

In caring for Marcia while receiving the PN via the central venous access catheter, which actions should be done by the nurse to prevent or identify potential complications? Select all that apply. Weighing her daily Monitoring the daily liver function tests Monitoring the daily electrolyte laboratory results Monitoring the daily serum albumin, prealbumin, transferrin levels Assessing her blood glucose every 6 hours for 48 hours, then daily

Weighing her daily Monitoring the daily electrolyte laboratory results Assessing her blood glucose every 6 hours for 48 hours, then daily RATIONALE: The nurse should weigh the client daily to monitor for weight gain. Electrolyte disturbances and hyperglycemia can occur in clients who are severely malnourished and started on PN. Therefore the daily electrolyte laboratory results and the blood glucose need to be monitored. Many infections occur with central lines and the risk of infection increases with the high levels of glucose that are present in the PN solution. Additionally, the central line dressing should be changed every 5 to 7 days or if moist, in accordance with CDC recommendations and the site. The liver function tests and serum albumin and transferrin levels will not change rapidly so they will not need to be monitored daily, usually they are monitored weekly.

The nurses determines which clients are candidates for parenteral nutrition (PN)? Select all that apply. A client with pneumonia A client with a severe burn injury A client with congestive heart failure A client scheduled for cholecystectomy A client with diabetes mellitus who has an ulcer on the right ankle A client undergoing chemotherapy who is experiencing severe vomiting and diarrhea

a client with a severe burn injury a client undergoing chemo who is experiencing severe vomiting and diarrhea RATIONALE: PN is indicated when the GI tract is severely dysfunctional or nonfunctional; when the client has undergone multiple GI surgeries or has sustained GI trauma; in clients experiencing severe intolerance of enteral feedings or intestinal obstruction; and in clients with other conditions in which the bowel needs to rest for healing. Conditions include AIDS, cancer, malnutrition, burns, chronic vomiting and diarrhea, diverticulitis, malnutrition, inflammatory bowel disease, pancreatitis, severe anorexia nervosa, and hypermetabolic states such as sepsis.

Spironolactone, a potassium-retaining diuretic, is prescribed for a client with heart failure, and the nurse provides medication instructions to the client. Which statement by the client indicates an understanding of the instructions? "I need to avoid foods that contain potassium." "I should take the medication on an empty stomach." "I need to eat a banana or drink a glass of orange juice every day." "I need to drink at least 10 to 12 glasses of water per day while I'm taking this medication."

"I need to avoid foods that contain potassium." RATIONALE: Spironolactone is a potassium-retaining diuretic. Therefore the client should avoid foods, such as bananas and orange juice, that contain potassium. The client should take the medication with food to enhance medication absorption. The client with heart failure should limit fluid intake as prescribed by the health care provider.

The nurse provides medication instructions to a client. Which statements by the client indicate the need for follow-up and additional teaching? Select all that apply. "I need to check my pulse before taking my heart medication." "I need to stop taking the medication if I have any side effects." "I can take herbal medications if I want, because they come from plants." "I should wear a Medic-Alert bracelet for as long as I'm taking this blood thinner." "I need to take this antibiotic until all of the capsules are all gone, even if I'm feeling better."

"I need to stop taking the medication if I have any side effects." "I can take herbal medications if I want, because they come from plants." One component of medication instructions is teaching the client how to take his temperature, pulse, and blood pressure. The client is also taught never to adjust a dose or abruptly stop taking a medication. If side effects or adverse effects occur, the client should contact the health care provider. Over-the-counter medication, including herbal preparations, must be avoided unless specifically approved by the health care provider, because they may interact with prescribed medications. Clients taking medications such as anticoagulants, oral hypoglycemics or insulin, certain cardiac medications, corticosteroids and glucocorticoids, antimyasthenic medications, anticonvulsants, and monoamine oxidase inhibitors need to wear a Medic-Alert bracelet or carry a Medic-Alert card. Medication compliance is important, and the importance of completing the prescribed medication regimen must be stressed to the client.

Allopurinol has been prescribed to treat hyperuricemia in a client with gout, and the nurse provides instructions to the client for the medication. Which statement by the client indicates the need for additional instruction? "I should take the medication with food." "I need to stop putting gravy on my food." "I'll need to limit my fluid intake while I'm taking this medication." "I'll need to have my blood level of the medicine checked while I'm taking it."

"I'll need to limit my fluid intake while I'm taking this medication." RATIONALE: Allopurinol, used to treat gout, reduces the concentrations of uric acid in serum and urine. The client should increase fluid intake to at least 2000 to 3000 mL/day to prevent renal injury. The client should also avoid foods high in purines (e.g., gravy, wine, alcohol, organ meats, sardines, salmon) to help decrease levels of uric acid. The medication should be taken with meals or milk to minimize GI distress. The client should have periodic complete blood cell counts, as well as determinations of serum and blood levels of uric acid, as prescribed.

Tranylcypromine sulfate is prescribed for a client with depression, and the nurse provides medication instructions to the client. Which statement by the client indicates a need for further instruction? "I shouldn't eat bananas." "I should get out of bed slowly in the morning." "I need to carry a Medic-Alert card in my wallet." "If I get a headache or any neck soreness, I can take some pain medication."

"If I get a headache or any neck soreness, I can take some pain medication." RATIONALE: Tranylcypromine sulfate, an MAOI, is used to treat depression. Certain pain medications, when combined with an MAOI, can cause a hypertensive crisis. The client is instructed to avoid consuming foods that contain tyramine (bananas) to help prevent hypertensive crisis. The client is also instructed to change position slowly to help prevent orthostatic hypotension and is told that signs of hypertensive crisis (e.g., headache or neck soreness or stiffness) must be reported to the health care provider immediately. The client is instructed to wear a Medic-Alert bracelet or carry a Medic-Alert card to alert others as necessary that an MAOI is being taken.

The nurse reads the medication label and rechecks the prescription (60 mg orally every 8 hours) to determine the amount of medication to be given. How many milliliters will the nurse give per dose to Caryn?

2.4 mL

A nurse provides medication instructions to a client with angina who will be taking nitroglycerin sublingually as needed for chest pain. Which statement by the client indicates the need for further teaching? "I should store the medication in a dark, tightly closed bottle." "I need to check the expiration date on the medication bottle." "If I get a headache from the medication, I can take acetaminophen." "If the first tablet doesn't relieve my chest pain, I should put 2 tablets under my tongue 5 minutes after taking the first."

"If the first tablet doesn't relieve my chest pain, I should put 2 tablets under my tongue 5 minutes after taking the first." RATIONALE: The nurse should instruct the client to take a sip of water before taking the medication, because mouth dryness may inhibit absorption. To terminate an acute anginal attack, sublingual nitroglycerin should be administered as soon as pain begins. Administration should not be delayed until the pain has become severe. According to current guidelines for the non-hospitalized client, if pain is not relieved in 5 minutes after taking the first nitroglycerin tablet, the client should call emergency medical services (911), since anginal pain that does not respond to nitroglycerin may indicate myocardial infarction. While awaiting emergency care, the client can take 1 more tablet, and then a third tablet 5 minutes later. The client should place the tablet under the tongue and allow it to fully dissolve. The nurse also instructs the client to store the medication in a dark, tightly closed bottle and to check the expiration date, because expiration may occur within 6 months of the medication's being dispensed. The client is instructed to take acetaminophen for headache.

A client with tuberculosis has been taking isoniazid, and now the health care provider has added rifampin to the medication regimen. The client calls the nurse and reports that her urine has been red-orange since she started taking the rifampin. Which response should the nurse give to the client? "This is an expected side effect of the rifampin." "Bring a urine specimen to the health care provider's office for analysis." "The change in urine color is a result of the combination of medications." "Increase your fluid intake. The medication may be causing hemorrhagic cystitis."

"This is an expected side effect of the rifampin." RATIONALE: Rifampin is an antitubercular medication that is used in conjunction with at least one other antitubercular medication for the treatment of tuberculosis. An expected side effect is a red-orange or red-brown discoloration of the urine, feces, saliva, skin, sweat, sputum, or tears. Because this side effect is expected, it is not necessary to have the client bring a specimen to the health care provider's office. The change in urine color is not a result of treatment with a combination of medications. Rifampin does not cause hemorrhagic cystitis, although some chemotherapeutic medications do cause this condition.

Carmela is preparing for discharge from the hospital. She has been receiving oral digoxin 0.125 mg/day and will be taking this medication after discharge. The nurse provides medication instructions to Carmela and her daughter. Which statement by Carmela's daughter indicates to the nurse that further instruction is needed? "It's important for her to eat foods that contain potassium." "We should expect visual disturbances with the medication." "We need to check her pulse rate before giving the medication." "She'll have to have blood tests from time to time to check the medication level."

"We should expect visual disturbances with the medication." RATIONALE: Digoxin, a cardiac glycoside, improves myocardial contraction. The nurse should teach the client the signs of digoxin toxicity and instruct the client to contact the health care provider if signs of toxicity occur. These signs include anorexia, nausea and vomiting, visual disturbances (e.g., diplopia, blurred vision, yellow-green halos), and bradycardia. The nurse also teaches the client how to measure the pulse and instructs the client to notify the health care provider if the pulse rate is slower than 60 or faster than 100 beats/min. The client is advised to eat foods high in potassium, because hypokalemia predisposes the client to toxicity. The client will need to have blood taken periodically for assessment of the digoxin level. The therapeutic digoxin range is 0.5 to 2.0 ng/mL; levels above 2.0 ng/mL are toxic.

A client is taking capreomycin sulfate as a component of pharmacological treatment for tuberculosis. The client calls the nurse at the health care provider's office and reports that he is experiencing ringing in the ears. How should the nurse respond? "You should stop taking the medication immediately." "Ringing in the ears is a harmless effect of the medication." "Ringing in the ears is an expected effect of the medication." "You need to speak to the health care provider about the problem."

"You need to speak to the health care provider about the problem." RATIONALE: Capreomycin is a second-line antituberculosis medication that is administered in conjunction with a first-line medication to treat tuberculosis. It can cause damage to cranial nerve VIII (ototoxicity), resulting in hearing loss, tinnitus, and disturbance of balance. If signs of ototoxicity occur, the health care provider must be notified. Ototoxicity is not an expected or harmless effect of the medication. The nurse does not adjust a dosage or discontinue a medication.

The nurse is participating in an interprofessional care conference. The health care provider tells the resident that the client needs an IV infusion of an isotonic solution. Which solution should the nurse expect the medical resident to prescribe? 0.9% NS 0.45% NS 10% dextrose in water 5% dextrose in 0.9% normal saline

0.9% NS An isotonic solution (a solution with the same osmolality as body fluids) increases the volume of extracellular fluid volume. One example of such a solution is 0.9% NS. A hypotonic solution is a solution that is more dilute or has a lower osmolality than body fluids — for instance, 0.45% NS. A hypertonic solution is more concentrated or has a higher osmolality than body fluids. Examples of such fluids include 10% dextrose in water and 5% dextrose in 0.9% normal saline solution.

A nurse has taught a client with type 1 diabetes mellitus how to draw up and mix the prescribed dose of NPH insulin 20 units and regular insulin 6 units. The nurse realizes the teaching has been effective if the client draws up the insulins in which order? 1) Putting 20 units of air into the NPH insulin bottle 2) Putting 6 units of air into the regular insulin bottle 3) Drawing up the regular insulin 4) Drawing up the NPH insulin

1, 2, 3, 4 When the prescribed treatment calls for the administration of both NPH and regular insulin, it is desirable to mix the two types rather than inject them separately, because this eliminates the need for a second injection. To prepare a mixture of NPH and regular insulin, the client should first add the air to the NPH insulin bottle, then add air to the regular insulin bottle, invert the bottle, and draw up the dose of regular insulin. The client would draw up the NPH insulin second.

The nurse assessing a client's IV site notes that the site is red and inflamed and feels warm. The nurse suspects phlebitis. In which order does the nurse take action? Restart the IV line in a different site Contact the health care provider Remove the IV catheter Apply a warm moist compress to the site

1. remove IV catheter 2. contact HCP 3. apply a warm moist compress to site 4. restart IV line in a different site If phlebitis at an IV site is suspected, the nurse first removes the IV catheter to prevent further inflammation and the possibility of thrombophlebitis. The health care provider is then notified of the occurrence. Application of a warm, moist compress to the area of phlebitis can help to decrease inflammation. A new IV line will need to be started at a different site, but the first action the nurse should take is to remove the existing line.

A nurse monitoring a client who is receiving intravenous theophylline checks the client's most recent blood theophylline level. The nurse documents that the level is in the therapeutic range if which value is reported? 8 mcg/mL 14 mcg/mL 24 mcg/mL 32 mcg/mL

14 mcg/mL RATIONALE: The therapeutic theophylline level ranges from 10 to 20 mcg/mL. If the level is below 10 mcg/mL, an increase in the infusion rate may be prescribed. A level greater than 20 mcg/mL indicates toxicity.

A health care provider prescribes heparin sodium 1200 units/hr by way of continuous IV infusion. The pharmacy prepares the medication and delivers an IV bag labeled "Heparin sodium 20,000 units per 250 mL D5W." An infusion pump must be used to administer the medication. At how many milliliters per hour does the nurse set the infusion pump to ensure delivery of 1200 units/hr?`

15 ml/hr Solving this problem requires a two-step process. First, determine the amount of heparin sodium in 1 mL. Next, determine the infusion rate, or milliliters per hour.

The nurse is caring for a client with breast cancer who has been undergoing chemotherapy. Blood tests indicate a low platelet count. A platelet transfusion is prescribed, and the nurse obtains the platelets from the blood bank. After carrying out the pretransfusion protocol, the nurse should administer the transfusion over what period of time? 2 hours 4 hours 6 hours 15 to 30 minutes`

15-30 mins The volume of a unit of platelets may vary from 200 mL for single-donor platelets to 300 mL per unit for pooled platelets. Because the platelet is a fragile cell, platelet transfusions are administered rapidly once they have been brought to the client's room, usually over the course of 15 to 30 minutes. The other options are time frames that are too long for the administration of a platelet transfusion.

A health care provider prescribes 1000 mL of normal saline solution to be infused over 10 hours. The drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? Round your answer to the nearest whole number

17 gtt/min

A prescription reads, "Penicillin G 1.2 million units intramuscular stat." The label on the prefilled syringe bears the notation "600,000 units/mL." How many milliliters of medication will the nurse prepare to administer to the client?

2

The nurse is working with a newly licensed nurse who is undergoing education prior to inserting an IV and is gathering the equipment needed to start an IV line in an older client who will be receiving an IV solution of 0.9% NS. The nurse realizes that teaching has been effective if the newly licensed nurse selects which gauge of catheter for this client? 14 16 19 21

21 For an older client, the smallest gauge IV catheter possible should be used. A gauge of 21 or smaller is preferred. A 14-, 16-, 18-, or 19-gauge needle is used for rapid emergency administration of fluids, blood products, or anesthetics, as well as other products of thicker viscosity than that of standard IV fluids. TEST-TAKING STRATEGY:

The safe dose of the prescribed medication is 40 mg/kg/day, divided into three doses. Using Caryn's weight in kilograms, the nurse determines the maximal daily dose of the medication that Caryn can safely be given. What is the maximal daily dose in milligrams?

228 mg

The ED health care provider writes a prescription for an IV catheter and tells the nurse that a hypertonic IV solution will be prescribed. The nurse reviews the health care provider's prescription. Which hypertonic solution does the nurse expect to see prescribed by the health care provider? 0.9% normal saline solution (NS) 5% dextrose in water 0.45% NS 5% dextrose in 0.45% NS

5% dextrose in 0.45% NS A hypertonic solution is a solution that is more concentrated or has a greater osmolality than body fluids. Examples of hypertonic solutions include 5% dextrose in 0.45% saline solution, 5% dextrose in 0.9% NS solution, 3% saline solution, 5% saline solution, 10% dextrose in water, and 5% dextrose in lactated Ringer's solution. The usual choice for replacement of fluids lost through the gastrointestinal system is 5% dextrose in 0.45% saline solution. An isotonic solution is a solution with the same osmolality as body fluids; such a solution increases extracellular fluid volume. Examples are 0.9% normal saline solution and 5% dextrose in water. A hypotonic solution is a solution that is more dilute or has a lesser osmolality than body fluids. One example is 0.45% NS.

Caryn weighs 12.5 lb. The nurse, determining whether the dosage prescribed for Caryn is safe, calculates Caryn's weight in kilograms. How many kilograms does Caryn weigh? (Round your answer to the nearest tenth.)

5.7 kg

The health care provider has prescribed 500 mL of 0.9 NS to infuse over 10 hours using a micro drip. The drop factor is 60 gtt/mL. The nurse obtains the necessary equipment and attaches the IV solution and tubing. At how many drops per minute does the nurse set the flow rate?

50 gtt/min

A client's dinner intake includes a glass of milk (8 oz), a cup of tea (6 oz), a glass of water (8 oz), and gelatin (4 oz). How many milliliters of fluid has the client consumed?

780 The client consumed a total of 26 oz of fluid. Because 1 oz is equal to 30 mL, you must multiply 26 oz by 30 mL, which yields 780 mL.

The nurse is preparing to administer lipids (fat emulsion) intravenously which has been sent up from the pharmacy in a glass bottle. Which items should the nurse obtain to help administer this solution? Select all that apply. Alcohol swab Thermometer 0.22-µm filter Vented intravenous tubing Bottle of lipids (fat emulsion) Blood pressure cuff and stethoscope

Alcohol swab Vented intravenous tubing Bottle of lipids (fat emulsion) RATIONALE: When administering lipids, the nurse will need the lipid solution, vented IV tubing, and an alcohol swab. Vented IV tubing is used because the lipid solution is supplied in a glass container for administration. The alcohol swab is needed to clean the IV port (on the primary IV tubing) at the site of insertion (piggyback) of the lipid tubing. An IV filter is not used to administer a lipid-emulsion only solution because particles in the lipid solution are too large to pass through filters. If the fat emulsion is to be added to the PN solution, then a filter gauge of 1.2 µm or larger is needed to allow it to pass through. A thermometer and blood pressure cuff are not necessary to help administer the solution; however, these items are needed to monitor the vital signs during the infusion.

Rectally administered lactulose is prescribed for a client with hepatic encephalopathy. Which parameter should the nurse monitor to evaluate the effectiveness of the medication? Blood pressure Ammonia level Electrolyte levels Looseness of stools

Ammonia level RATIONALE: Lactulose is a hyperosmotic laxative and ammonia detoxicant. It can enhance intestinal excretion of ammonia and decrease the blood ammonia level in a client with portal hypertension and hepatic encephalopathy. Diarrhea is an indicator of overdose, not effectiveness. Used correctly, the medication should result in the production of two or three soft stools per day. Blood pressure is not associated with the action or effectiveness of this medication. Electrolyte levels are monitored in clients who must take this medication frequently, in large doses, or for prolonged periods because of the risk of electrolyte disturbance.

A client who is receiving a continuous IV infusion through a peripheral site suddenly complains of pain along the vein at the location of the catheter. The nurse quickly assesses the client and notes a weak, rapid pulse; cyanosis of the nail beds; and a decrease in blood pressure. Suspecting catheter embolism, the nurse removes the IV catheter and sees that the tip of the catheter has broken off. What immediate action should the nurse take? Start an IV line at a different site Apply a tourniquet high on the limb of the IV site Call the operating room to alert the staff that the client will need surgery Call the radiography department to request an x-ray of the client's arm and shoulder

Apply a tourniquet high on limb of IV site A catheter embolism occurs when the tip of the IV catheter breaks off and floats freely in a vessel. This can lead to an embolus. The signs of catheter embolism include pain along the vein; diminished blood pressure; weak, rapid pulse; cyanosis of the nail beds; and loss of consciousness. The nurse would remove the catheter carefully, inspect the catheter once it has been removed, and place a tourniquet high on the limb containing the IV site if the catheter tip has broken off. The health care provider is then notified. The client is prepared for anx-ray and for surgery to remove catheter fragments, if prescribed

A nurse is instructing a client about the use of sulfisoxazole, which has been prescribed to treat the client's urinary tract infection. Which instructions should the nurse provide to the client? Select all that apply. Expect itching to develop. Limit fluid intake to prevent edema. Apply sunscreen if exposure to sunlight is expected. Use over-the-counter corticosteroid cream for itchy rash. Take the medication on an empty stomach with a full glass of water.

Apply sunscreen if exposure to sunlight is expected. Take the medication on an empty stomach with a full glass of water. RATIONALE: Sulfisoxazole is a sulfonamide. The appearance of a rash indicates hypersensitivity to the medication; the client is instructed to stop the medication and contact the health care provider if itching or a rash occurs. The client should not use over-the-counter medications unless they are specifically prescribed. The client is also instructed to take the medication on an empty stomach with a full glass of water; to avoid prolonged exposure to sunlight, wear protective clothing when in the sun, and apply a sunscreen to skin exposed to sunlight; and to consume eight to 10 glasses of water each day to minimize the risk of renal damage.

A nurse is observing a new nurse employee who is preparing to administer 1 inch (2.5 cm) of topical nitroglycerin ointment to a client with angina pectoris. Which actions indicate the new nurse employee needs further education? Select all that apply. Wearing gloves Applying the ointment to skin with hair Removing previously applied ointment Rubbing the ointment into the client's skin Measuring out the correct amount of ointment on the paper applicator Taping the paper applicator in place once the ointment has been applied

Applying the ointment to skin with hair Rubbing the ointment into the client's skin To promote medication absorption as intended, the nurse would avoid applying the ointment to skin with hair and would also avoid rubbing the ointment into the skin. The nurse always wears gloves when applying topical medications to a client; in this case, gloves are especially important because the nurse could be subject to the effects of the medication if it were to come into contact with the nurse's skin. Before applying nitroglycerin ointment, the nurse would remove the previously applied ointment and cleanse the skin. The correct amount of medication is measured out on the appropriate paper applicator, after which the applicator is taped in place on the client's body

A client with Hodgkin's disease will be receiving chemotherapy with doxorubicin. Which action should the nurse plan to take as a means of monitoring the client for toxicity specific to this medication? Checking the client's temperature Attaching a cardiac monitor to the client Assessing the client for peripheral edema Drawing a blood specimen to check the client's platelet count

Attaching a cardiac monitor to the client RATIONALE: Doxorubicin can cause both acute and delayed injury to the heart. Acute effects (dysrhythmias, electrocardiographic changes) may develop within minutes of administration. (In most cases these reactions are transient, lasting no more than 2 weeks.) Delayed cardiotoxicity, which appears as heart failure resulting from diffuse cardiomyopathy, is often unresponsive to treatment. Checking the client's temperature, assessing the client for peripheral edema, and checking the client's platelet count may all be sound nursing interventions, but they are not specifically related to cardiotoxicity, a toxic effect of doxorubicin.

A pregnant client with preeclampsia is receiving an IV infusion of magnesium sulfate. Which medication, the antidote to magnesium sulfate, does the nurse ensure is readily available? Vitamin K Acetylcysteine Protamine sulfate Calcium gluconate

Calcium gluconate RATIONALE: Magnesium sulfate is a CNS depressant and anticonvulsant. It causes smooth muscle relaxation and is used to stop preterm labor to prevent preterm birth and prevent and control seizures in preeclamptic and eclamptic clients. Calcium gluconate, which acts as the antidote to magnesium, should be placed in the room of the client receiving magnesium sulfate. Vitamin K is the antidote to warfarin. Protamine sulfate is the antidote to heparin. Acetylcysteine is the antidote to acetaminophen.

Caryn's condition worsens. The health care provider has changed the amoxicillin prescription to nafcillin 200 mg intramuscularly every 6 hours. The drug literature indicates that this medication can be safely given at a dosage of 100 mg/kg/day, divided into 4 to 6 doses. The vial is labeled "1 g" and will be reconstituted with 3.4 mL of diluent, which equals 4 mL in the vial. How will the nurse respond to this prescription? Arrange the actions in the order that they should be performed. All options must be used. Calculate the amount of medication to draw up. Calculate the safe dose. Wash hands. Call the health care provider to clarify the prescription. Select the appropriate medication vial.

Calculate the safe dose. Call the health care provider to clarify the prescription. Select the appropriate medication vial. Calculate the amount of medication to draw up. Wash hands.

A nurse reviewing laboratory results sees that the serum phenytoin level of a client who is taking oral phenytoin, 300 mg/day, is 22 mcg/mL. Which action should the nurse take first on the basis of this finding? Call the client's health care provider Administer the next scheduled dose Place the laboratory result form in the client's record Inform the client that the result is within the therapeutic range

Call the client's health care provider RATIONALE: The therapeutic serum range of phenytoin is 10 to 20 mcg/mL. A level below 10 mcg/mL is too low to control seizures and reflects a need to increase the dosage of phenytoin. A level higher than 20 mcg/mL indicates toxicity and a need to notify the health care provider. The nurse would place the laboratory results in the client's record after notifying the health care provider.

Timolol maleate eyedrops have been prescribed to reduce intraocular pressure in a client with open-angle glaucoma. When teaching the client about the medication, the nurse ensures that the client knows how to perform which procedure? Check his pulse Measure his weight Take his temperature Measure his intake and output

Check his pulse RATIONALE: Timolol maleate is a beta-adrenergic-blocking medication that reduces intraocular pressure by diminishing the production of aqueous humor. Beta-blockers can be absorbed in amounts sufficient to cause systemic effects. Blockade of cardiac beta-1 receptors can produce bradycardia and atrioventricular heart block. Therefore the client should be taught how to take the pulse. Weight, temperature, and intake and output are not directly related to the action or side/adverse effects of this medication.

A central venous catheter is inserted for the administration of PN. Which action should the nurse take to confirm correct placement of the catheter? Auscultates the lungs Checks the results of the post-insertion chest x-ray with the health care provider Checks the insertion site for signs of infiltration while the PN solution is being infused Attaches a syringe to the central venous access catheter and pulls back on the plunger of the syringe, looking for backflow of blood

Checks the results of the post-insertion chest x-ray with the health care provider

Two registered nurses confirming blood product compatibility and verifying client identity for a client who is to receive a unit of packed RBCs are comparing the name and number on the client's identification band with the name and number on the unit of blood. The nurses note that the numbers are not identical. What should the nurses do? Hang the unit of blood Contact the blood bank Continue verifying client identity, then notify the health care provider Ask the unit secretary to prepare another identification band for the client that contains the number noted on the unit of blood

Contact the blood bank Two licensed nurses must check the health care provider's prescription, the client's identity, and the client's identification band and number, verifying that the name and number are identical to those on the blood component tag. At the bedside, the client is asked to state his or her name, which the nurse compares with the name on the client's ID band. The blood bag tag and label and the blood requisition form are assessed to ensure that ABO and Rh types are compatible, and the blood bag label is also checked to ensure that the correct components have been issued. If an inconsistency is found, the blood bank is notified immediately. Hanging the unit of blood, continuing to verify the client's identity, notifying the health care provider, and asking the unit secretary to prepare another identification band for the client that contains the number noted on the unit of blood are all incorrect choices. Additionally, there is no useful reason to notify the health care provider.

A client with terminal cancer is receiving morphine sulfate by way of continuous IV infusion. The nurse checks the client's vital signs and notes a pulse rate of 68 beats/min, a blood pressure of 100/58 mm Hg, and a respiratory rate of 10 breaths/min. Which action should the nurse take? Decrease the rate of infusion Contact the health care provider Ask the client to rate the pain level Continue to monitor the client's vital signs

Contact the health care provider RATIONALE: Respiratory depression is the most serious adverse effect of morphine sulfate. If the client's respiratory rate is slower than 12 breaths/min or if bradycardia develops (slower than 60 beats/min), the nurse would withhold the medication (not just decrease the rate of the infusion) and notify the health care provider. Although the nurse would assess the client's pain level and continue to monitor the client's vital signs, contacting the health care provider is the appropriate action.

The nurse is monitoring a client receiving a blood transfusion. One hour after the transfusion is started, the client complains that her skin is extremely itchy. On assessing the client's skin, the nurse notes a rash and suspects a transfusion reaction. Which action should the nurse take after immediately stopping the transfusion? Removing the IV catheter Contacting the health care provider Completing a transfusion reaction report Rechecking the blood bag tags against the client's identification band

Contacting the health care provider When a transfusion reaction occurs, the nurse first stops the blood transfusion, then maintains a patent IV line with normal saline solution and immediately notifies the health care provider and blood bank. After taking these actions, the nurse would recheck the blood bag tags against the client's identification band, check the client's vital signs and urine output, treat the client's symptoms in accordance with the health care provider's prescriptions, send the blood bag and tubing to the blood bank, complete a transfusion reaction report and document the reaction in the client's record, and collect required blood and urine samples in accordance with agency protocol and health care provider's prescriptions.

The nurse is preparing to administer Carmela's hospital prescribed medications: captopril, furosemide, metoprolol, and digoxin. Which nursing actions are essential before the medications are administered? Select all that apply. Checking fluid balance Counting the apical heart rate Measuring the blood pressure Assessing the client for hypokalemia Performing a complete physical assessment

Counting the apical heart rate Measuring the blood pressure Assessing the client for hypokalemia RATIONALE: Assessment for hypokalemia is especially important for the client receiving captopril, an ACE inhibitor, when given concurrently with diuretic therapy. Carmela's diuretic medication is furosemide, a loop diuretic, which frequently contributes to decreasing blood pressure and frequently causes hypokalemia. Hypokalemia may result in changes in muscle strength, tremor, muscle cramps, altered mental status, and cardiac dysrhythmias. Also hypokalemia may increase the occurrence of digoxin toxicity. Fluid balance would be checked because of the captopril and furosemide. Metoprolol, a beta-blocker, blocks the release of the catecholamines epinephrine and norepinephrine thereby decreasing the heart rate and blood pressure. With metoprolol the side/adverse effects include headache, palpitations, tachycardia, and peripheral edema of hands, feet. Nausea, dyspepsia, abdominal cramps, diarrhea, or constipation can also be side effects of these medications. Digoxin will decrease the heart rate and could affect the heart rhythm. Therefore the nurse would check the client's apical pulse and blood pressure immediately before administering the medications. If the pulse is slower than 60 or greater than 100 beats/min or the systolic blood pressure is below 90 mm Hg, the digoxin and metoprolol are withheld and the health care provider notified. It is not necessary to conduct a complete physical assessment; rather a focused assessment should be performed.

The nurse suspects hyperglycemia in the client who is receiving parenteral nutrition (PN) if which signs/symptoms are noted? Select all that apply. Seizures Sweating Diaphoresis Excessive thirst Increased urine output Kussmaul respirations

Excessive thirst Increased urine output Kussmaul respirations RATIONALE: The high concentration of glucose in PN puts the client at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul respirations, diuresis, and, in severe cases, coma. If a client presents with these symptoms, the blood glucose level should be checked immediately. Seizures, sweating, and diaphoresis are signs of hypoglycemia.

The nurse asks Helena whether she has ever received a blood transfusion. Helena tells the nurse that she had one transfusion years ago but that "they had to stop it because I got the chills and a rash all over my body." After gathering additional information from Helena, the nurse reports the findings to the health care provider. The health care provider prescribes premedication with intravenous (IV) diphenhydramine hydrochloride. When does the nurse plan to administer the diphenhydramine hydrochloride? 1 hour before the transfusion is started 15 minutes after the transfusion is started 30 minutes before the transfusion is started Immediately before the transfusion is started

Immediately before the transfusion is started A history of an allergic reaction may warrant the administration of an antihistamine such as diphenhydramine hydrochloride. IV medication should be given immediately before the transfusion is started. If an oral medication is prescribed, it should be administered 30 minutes before the transfusion is started. Administering the medication after the infusion has been started will make the medication less effective in reducing the risk of a transfusion reaction.

A client has been given instructions regarding the recently prescribed levothyroxine. The nurse determines the teaching was effective if the client states the medication should be taken in which manner? With food At bedtime With a snack at 3 p.m. In the morning, on an empty stomach

In the morning, on an empty stomach RATIONALE: Levothyroxine should be taken on an empty stomach to enhance its absorption. The daily dose should be taken in the morning, 1 hour before breakfast. Therefore, the remaining options are incorrect.

The IV catheter is inserted and infusion of the prescribed solution is started. The ED nurse transports Josephine to the medical unit for admission and provides a detailed report on her status to the nurse on the medical unit. On admission to the medical unit, Josephine complains of pain at the venipuncture site. Checking the venipuncture site, the nurse notes that it is swollen and cool to touch and also sees that the solution is not infusing. How does the nurse interpret these findings? The IV line needs to be flushed. Infiltration of the IV site has occurred. Phlebitis caused by the IV catheter is beginning to set in. Heat should be applied to the venipuncture site to dilate the vein so that the solution will infuse as prescribed.

Infiltration of the IV site has occurred. Infiltration is a form of tissue damage caused by seepage of IV fluid from the vein into the surrounding interstitial spaces. It occurs when a catheter is dislodged or perforates the wall of the vein or when venous back-pressure occurs as a result of a clot or venospasm. The affected client will complain of discomfort at the venipuncture site, and the nurse will note swelling and coolness. The nurse would not flush an IV in a site that has been infiltrated. Flushing would increase pressure in the tissues, resulting in pain and additional tissue damage. Although heat may be prescribed to treat infiltration and relieve discomfort, it is not used to dilate the vein. Phlebitis is characterized by pain, redness, warmth, and edema at the venipuncture site.

The emergency department nurse, preparing to insert an IV catheter, assesses Josephine for an appropriate venipuncture site. Which site should the nurse select as the best place to insert the catheter? Left foot Right hand Left inner arm Right inner arm

Left inner arm The hand and arm are commonly used venipuncture sites. The foot may be selected for a small child but is avoided in the adult because of the risk of thrombophlebitis. The antecubital area may be used, but frequent bending of the elbow may obstruct the flow of solution, resulting in infiltration that could lead to thrombophlebitis. A distal site should be used first to permit the later use of proximal sites if the client requires a venipuncture site change. However, in this client the right hand and forearm must be avoided because the client has sustained open-skin injuries in a fall. Of the options provided, the inner left arm is the best venipuncture site for Josephine.

Which guidelines are appropriate for use by the nurse administering the intramuscular injection to Caryn? Select all that apply. Inject into the vastus lateralis muscle. Use the ventrogluteal muscle for the injection. Use a 1½-inch (3.8 cm) 20-gauge needle and 3-mL syringe. Ask someone else to hold the infant while you give the injection. Use a ½-inch (1.25 cm) 25-gauge needle to administer the medication.

Inject into the vastus lateralis muscle. Ask someone else to hold the infant while you give the injection. Use a ½-inch (1.25 cm) 25-gauge needle to administer the medication. The only muscle large enough for intramuscular injections in the infant is the vastus lateralis. The nurse should ask someone else to hold the infant to help prevent damage resulting from movement during the injection. Another nurse or a parent may help hold the child. The needle should be ½ inch long, 25 gauge, because of the infant's small muscle mass. The ventrogluteal muscle is used in children older than 18 months and in adults. A 1½-inch 20-gauge needle is too long and too large.

The nurse has confirmed correct catheter placement and is preparing to administer the PN solution. Which actions should the nurse take? Select all that apply. Obtaining an electronic infusion device Checking the PN solution for clarity and color Hanging the PN solution as soon as it is removed from the refrigerator Checking the components of the PN solution against the health care provider's prescription Using IV tubing that will allow concurrent administration of prescribed IV medications, albumin, and blood products

Obtaining an electronic infusion device Checking the PN solution for clarity and color Checking the components of the PN solution against the health care provider's prescription RATIONALE: To prevent fluid overload, PN is always administered with the use of an electronic infusion device. The PN solution is checked for clarity and color (the solution should be clear but may appear yellow because of the addition of vitamins) to ensure that the solution is not contaminated. The nurse always checks the components of the PN solution against the health care provider's prescription to ensure that the client is receiving the prescribed nutrition. PN solution contains a high concentration of glucose, making it an excellent medium for the growth of bacteria. Therefore PN that is not being used is refrigerated. The solution should be removed from the refrigerator 30 minutes to 1 hour before use to allow the temperature of the solution to warm to room temperature. Medications, albumin and blood are not administered through the PN line because of the possibility of incompatibilities.

A client receiving PN is exhibiting signs of an air embolism. Immediately after placing the client's head lower than the feet, how should the nurse next position the client? Prone On her back On the left side On the right side

On the left side

The nurse is monitoring a client who is receiving IV fluids through a central line inserted into the subclavian vein. The client suddenly complains of chest pain and difficulty breathing. The nurse notes that the client's pulse rate has increased, that the client is hypotensive, and that a loud churning sound is audible on auscultation over the precordium. The nurse suspects air embolism. Which immediate action should the nurse take? Removing the IV catheter Calling the resuscitation team Elevating the head of the client's bed Placing the client in left lateral Trendelenburg position

Placing the client in left lateral Trendelenburg position Air embolism occurs when air enters the central venous system during catheter insertion, tubing changes, or breakage of the catheter. Signs include chest pain, tachycardia, dyspnea, hypotension, cyanosis, and a decreased level of consciousness. A loud churning sound may be heard over the precordium, a result of air in the right ventricle. If air embolism occurs, the nurse immediately clamps the catheter (but does not remove it), places the client in the left lateral Trendelenburg position to trap the air in the right atrium, and notifies the health care provider. There is no information in the question to indicate that the resuscitation team should be called.

Levodopa is prescribed for a client with Parkinson disease. Which vitamin does the nurse instruct the client to avoid while taking the levodopa? Thiamine Riboflavin Pyridoxine Ascorbic acid

Pyridoxine RATIONALE: Pyridoxine can decrease the amount of levodopa that reaches the CNS. As a result, the therapeutic effect of levodopa is reduced. The client taking levodopa should be informed about this interaction and instructed to avoid multivitamin preparations containing pyridoxine. Thiamine, riboflavin, and ascorbic acid do not need to be avoided by the client taking levodopa; these medications do not affect the amount of levodopa reaching the CNS.

An IV catheter was inserted into a client 1 hour ago. Assessing the IV site, the nurse notes the presence of bruising. The nurse also finds that the area is swollen, and the client complains of pain at the site. Which action by the nurse is most appropriate? Notifying the health care provider of the findings Removing the IV catheter and applying pressure to the site Elevating the extremity and rechecking the site in 1 hour for a decrease in the swelling Telling the client that the bruising is normal and occurred as a result of the IV insertion

Removing the IV catheter and applying pressure to the site A hematoma is a collection of blood in the tissue that occurs after an unsuccessful venipuncture or after a venipuncture is discontinued. It is characterized by discoloration, bruising, and swelling around the IV site. The client may also complain of pain at the site. If a hematoma develops, the nurse removes the IV catheter, elevates the extremity, and applies pressure. This occurrence is not normal, but it is not necessary to notify the health care provider of this complication unless agency policy indicates that this should be done.

The nurse has obtained a unit of packed RBCs from the blood bank for administration to a client. While preparing to administer the transfusion, the nurse is called to attend to an emergency involving another client. Before leaving to go to the other client, what should the nurse ask another staff member to do? Return the blood to the blood bank Place the blood in the nursing unit's refrigerator Attach the blood to the client's IV line because the client's identity and the identifying information on the unit of blood have already been matched Bring the unit of blood to the client's bedside and explain to the client that the blood will be infused once the emergency situation has been taken care of

Return the blood to the blood bank Blood bank safety protocol dictates that refrigerated blood components not be returned to inventory if they have been warmed to more than 10° C (50° F). Therefore the maximal amount of time for which a unit of blood can be out of storage is 30 minutes. Thus, the nurse would not leave the unit of blood at the client's bedside or attach it to the client's IV line. Blood is not placed in the nursing unit refrigerator, because its temperature may not be adequate for blood storage. The appropriate nursing action is to have the unit of blood returned to the blood bank.

The nurse obtains a bag of parenteral nutrition (PN) solution from the nursing unit refrigerator. On inspecting the solution, the nurse notes that it is cloudy. Which action should the nurse take? Return the solution to the pharmacy Shake the solution vigorously to disperse the cloudiness Assume that the lipids (fat emulsion) has been added to the PN solution Allow the solution to warm to room temperature and then recheck the solution

Return the solution to the pharmacy RATIONALE: The nurse must check the PN solution before administering it. Cloudiness is a sign of contamination. If contamination is suspected, the only safe option is to promptly return the solution to the pharmacy. Shaking the solution vigorously to disperse the cloudiness, assuming that the lipid emulsion has been added to the solution, and allowing the solution to warm to room temperature and rechecking it are all incorrect actions that do not address the abnormal finding.

A topical glucocorticoid preparation has been prescribed for a client in whom local dermatitis has developed as a result of an insect bite. What should the nurse include when teaching the client about the medication? Rub the cream gently into the skin Cover the site with plastic wrap after applying the cream Apply an occlusive dressing over the site after applying the cream Apply the cream in a thick layer over the site of the bite and on 2 inches of surrounding skin

Rub the cream gently into the skin RATIONALE: Topical glucocorticoids can be absorbed into the systemic circulation. Therefore they should be applied in a thin layer and gently rubbed into the skin. The client is told not to use occlusive dressings (e.g., bandages, plastic wrap) unless instructed to do so by the health care provider.

The nurse determines that Marcia has demonstrated an effective response to parenteral nutrition (PN) if which is noted? She shows no signs of infection She states that she is less fatigued She is gaining one pound per week Her blood urea nitrogen and creatinine levels are within the normal ranges

She is gaining one pound per week RATIONALE: The expected outcome for a client receiving PN is maintenance of ideal body weight or a gain of one to two pounds each week until the ideal body weight is achieved. A decrease in fatigue and the blood urea nitrogen and creatinine levels into the normal ranges indicate improvement in the client's condition but do not specifically indicate an effective response to PN. Showing no signs of infection is unrelated to an effective response to PN administration.

Oral prednisone, 10 mg/day, has been prescribed for a hospitalized client with a history of type 1 diabetes mellitus for the treatment of an acute exacerbation of asthma. The nurse should monitor the client closely for which occurrence? Signs of hypoglycemia Signs of hyperglycemia The need to decrease the prescribed daily insulin dose The need to change the prescribed daily insulin to an oral hypoglycemic medication

Signs of hyperglycemia RATIONALE: Because of their effect on glucose production and utilization, glucocorticoids can increase the plasma glucose level, causing hyperglycemia and glycosuria. Clients with diabetes mellitus may need to increase the dosage of insulin or oral hypoglycemic medications during treatment with a glucocorticoid. Decreasing the prescribed insulin dose, needing to change the prescribed insulin to an oral hypoglycemic medication, and watching for signs of hypoglycemia are all therefore incorrect.

The nurse is working with a new nurse employee who is hanging a unit of packed RBCs. The nurse realizes the new nurse employee has taken correct action if the nurse takes which step once the nurse has hung the blood and adjusted the flow rate? Taking the client's vital signs Staying with the client and monitoring him closely for 15 minutes Asking the client whether he has ever had a reaction to a blood transfusion Placing the call bell next to the client and instructing him to call if he experiences anything unusual

Staying with the client and monitoring him closely for 15 minutes The first 10 to 15 minutes of any transfusion is the most critical period. If a major ABO incompatibility exists or a severe allergic reaction such as anaphylaxis is going to occur, it is usually evident within the first 50 mL of the transfusion. Therefore the transfusion should be started at a slow rate and the client monitored closely for the first 15 minutes. If no reaction is noted during the first 15 minutes, the infusion may be increased to the prescribed rate. The client is asked about previous reactions to blood transfusions before the blood is infused. Vital signs are taken before the transfusion is begun, after the first 15 minutes, and every hour until 1 hour has elapsed since the transfusion was completed. Before leaving the client, the nurse places the call bell next to him and instructs him to call if he experiences any unusual feelings or emotions.

A pregnant client is receiving an IV infusion of oxytocin. Monitoring the client closely, the nurse suddenly notes the presence of uterine hypertonicity. Which action should the nurse take immediately? Document the finding Turn the client on her side Stop the oxytocin infusion Increase the rate of infusion of the nonadditive IV solution

Stop the oxytocin infusion RATIONALE: Oxytocin is an oxytocic agent used to induce labor. If uterine hypertonicity or a nonreassuring FHR occurs, the nurse must intervene to reduce uterine activity and increase fetal oxygenation. The nurse would immediately stop the oxytocin infusion, increase the rate of the nonadditive (e.g., normal saline) IV solution, place the client in a side-lying position, and administer oxygen by way of face mask at a rate of 8 to 10 L/minute. The nurse would then notify the health care provider, continue monitoring the client, and document the occurrence and findings. However, the immediate action is stopping the infusion.

The nurse is monitoring Helena closely during the infusion of the blood. One hour after the blood transfusion is started, Helena complains of chills and a backache, and a transfusion reaction is suspected. Prioritize the following steps that will be taken by the nurse, with 1 as the first step and 5 as the last. Checking vital signs and urine output Contacting the primary health care provider and blood bank Keeping the IV line open with 0.9% saline solution Stopping the transfusion Completing a transfusion reaction report

Stopping the transfusion Keeping the IV line open with 0.9% saline solution Contacting the primary health care provider and blood bank Checking vital signs and urine output Completing a transfusion reaction report If a transfusion reaction is suspected, the transfusion is immediately stopped and NS infused, pending further primary health care provider prescriptions. NS is the solution of choice, rather than solutions containing dextrose, because red blood cells do not clump with NS. Ensuring patent IV access also helps maintain the client's intravascular volume, while also providing access for emergency medications given intravenously. Next, the health care provider should be notified because a transfusion reaction is an emergency situation. Vital signs and oxygen saturation are monitored closely. Finally, the nurse documents the findings and the client's response to the interventions.

Cyclosporine is prescribed for a client who has undergone a kidney transplant. Which should the nurse plan to monitor most closely? Temperature Platelet count Apical heart rate Peripheral pulses

Temperature RATIONALE: Cyclosporine is an immunosuppressant used to prevent organ rejection. The most common adverse effects of cyclosporine are nephrotoxicity, infection, hypertension, tremor, and hirsutism. Of these, nephrotoxicity and infection are the most important. Therefore the client's temperature should be monitored closely, because an increase in temperature is an indication of infection. Apical heart rate, platelet count, and peripheral pulses are not specifically associated with the effects of this medication.

After the transfusion reaction, the nurse tells Helena that a urine specimen must be obtained and sent to the laboratory for testing. Helena asks the nurse what the urine is being tested for. What does the nurse tell Helena? Protein Bacteria The presence of white blood cells (WBCs) The breakdown of red blood cells (RBCs)

The breakdown of red blood cells (RBCs) After a transfusion reaction, a urine specimen is obtained and evaluated for hemolysis. When an acute reaction occurs, antibodies in the client's serum react with antigens on the donor's RBCs. This results in agglutination of cells, which can obstruct capillaries and block blood flow. Hemolysis of RBCs releases free hemoglobin into the plasma. The hemoglobin is filtered by the kidneys and may be found in the urine (hemoglobinuria). Hemoglobin may obstruct the renal tubules, leading to acute renal failure. Free hemoglobin in blood and urine specimens obtained at the onset of the reaction provides evidence of an acute hemolytic reaction. Protein, bacteria, and the presence of WBCs are unrelated to a transfusion reaction.

A nurse is preparing to administer digoxin, 0.125 mg orally, to a client with heart failure. Which findings indicate the need to withhold the medication and contact the health care provider? Select all that apply. The client complains of being hungry. The client complains of double vision. The client's digoxin level is 1.8 ng/mL. The client's potassium level is 3.0 mEq/L (3.0 mmol/L). The client's apical heart rate is 62 beats/min.

The client complains of double vision. The client's potassium level is 3.0 mEq/L (3.0 mmol/L). RATIONALE: The therapeutic (digoxin) level ranges from 0.5 to 2.0 ng/mL. Signs of toxicity include anorexia or nausea and vomiting; visual disturbances: diplopia, blurred vision, yellow-green halos; bradycardia (heart rate slower than 60 beats/min); and photophobia. The health care provider is alerted if signs of toxicity are noted. An increased risk of toxicity exists in clients with hypokalemia, so the health care provider is notified if hypokalemia is present. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

Buspirone, a nonbenzodiazepine anxiolytic, is prescribed for a client to treat anxiety, and the nurse provides information to the client about the medication. The nurse should provide which information to the client? The medication is addictive. The medication does not usually cause sedation. The medication relieves anxiety immediately, with the first dose. The medication can intensify the effects of other CNS depressants.

The medication does not usually cause sedation. RATIONALE: Buspirone is an anxiolytic used to reduce anxiety. Common side effects include dizziness, nausea, headache, nervousness, lightedheadedness, and excitement. It does not usually cause sedation, has no abuse potential, and does not intensify the effects of CNS depressants. Antianxiety effects take at least a week to develop.

A client with breast cancer who has undergone a mastectomy will be receiving chemotherapy. The oncologist prescribes allopurinol, 100 mg orally daily, to be started before the initiation of chemotherapy. The nurse should tell the client that this medication is used for which purpose? To prevent nausea To prevent diarrhea To reduce postoperative incision pain To minimize an increase in the plasma uric acid level

To minimize an increase in the plasma uric acid level RATIONALE: Allopurinol is used to reduce the blood level of uric acid. The level of uric acid increases as a result of the breakdown of DNA that occurs after chemotherapy-induced cell death. As a means of minimizing any increase in the plasma level of uric acid, allopurinol should be administered before the start of chemotherapy. Allopurinol does not prevent nausea or diarrhea or reduce incision pain.

A nurse is preparing to administer enteric-coated acetylsalicylic acid tablets orally to a client. When the nurse brings the medication to the client, the client tells the nurse that she has difficulty swallowing and will not be able to swallow the pills. Which action is most appropriate for the nurse to take? Contacting the health care provider Administering an elixir form of the medication Crushing the pills and mixing them into applesauce Administering the suppository form of the medication

contacting the health care provider Enteric-coated tablets, which are absorbed in the small intestine, should not be crushed, because the medication could irritate the stomach. For these reasons, an elixir form of a medication should not be given in place of enteric-coated tablets. Also, aspirin is not available in elixir form. The nurse would not administer a medication by way of a route that had not been prescribed. Thus the only correct option is to contact the health care provider.

The nurse is developing a plan of care for a client who will receive a continuous IV infusion of 5% dextrose at a rate of 100 mL/hr. How frequently should the nurse plan to change the bag of IV fluids? Weekly Every 24 hours Every 48 hours Every 72 hours

every 24 hours As a means of helping prevent complications associated with IV therapy (systemic infection), the bag of IV fluids should be changed every 24 hours. Other times, such as every 48 to 72 hours or weekly, would allow time for bacteria to proliferate.