Saunders Exam 3
The nurse provides instructions to a client who has a prescription for ticlopidine. Which statement made by the client indicates a need for further teaching? "I'll take my medicine with meals." "Blood work will be done every 2 weeks for the first 3 months." "I would not stop the medication without talking to my doctor first." "Food will affect the medication, so I need to take the medication on an empty stomach."
"Food will affect the medication, so I need to take the medication on an empty stomach." Rationale: Ticlopidine is an antiplatelet agent that is used for the prevention of thrombotic stroke. Ticlopidine is best tolerated when taken with meals. Blood work is monitored closely, particularly in early therapy, because the medication can cause neutropenia. A client would not stop medication without the primary health care provider's permission.
The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching? "I would keep the insulin in the cabinet during the day only." "I know I have to keep my insulin in the refrigerator at all times." "I can store the open insulin bottle in the kitchen cabinet for 1 month." "The best place for my insulin is on the windowsill, but in the cupboard is just as good."
"I can store the open insulin bottle in the kitchen cabinet for 1 month." Rationale: An insulin vial in current use can be kept at room temperature for 1 month without significant loss of activity. Direct sunlight and heat must be avoided. Therefore, options 1, 2, and 4 are incorrect.
The home care nurse is making a monthly visit to a client with a diagnosis of pernicious anemia who has been receiving a monthly injection of cyanocobalamin. Before administering the injection, the nurse evaluates the effects of the medication and determines that a therapeutic effect is occurring if the client makes which statement? "I feel really light-headed." "I no longer have any nausea." "I have not had any pain in a month." "I feel stronger and have a much better appetite."
"I feel stronger and have a much better appetite." Rationale: Cyanocobalamin is essential for DNA synthesis. It can take up to 3 years for the vitamin B12 stores to be depleted and for symptoms of pernicious anemia to appear. Symptoms can include weakness, fatigue, anorexia, loss of taste, and diarrhea. To correct deficiencies, a crystalline form of vitamin B12, cyanocobalamin, can be given intramuscularly. The client statements in options 1, 2, and 3 do not identify a therapeutic effect of the medication.
The nurse has a routine prescription to administer an injection of phytonadione (vitamin K) to the newborn. Which statement made by the new birthing parent indicates that teaching on this medication was effective? "I know that this medication is used to stimulate the liver to produce vitamin K." "I know that this medication is used to prevent clotting abnormalities in the newborn." "I know that this medication is used to prevent vitamin deficiency of fat-soluble vitamins." "I know that this medication is used to supplement my baby because breast/chest milk and formula are low in vitamin K."
"I know that this medication is used to prevent clotting abnormalities in the newborn." Rationale: Vitamin K is given to the newborn to prevent clotting abnormalities. Vitamin K is usually produced by bacteria in the gastrointestinal tract, which is sterile in the newborn. The other options are incorrect reasons for administering this medication to a newborn.
The nurse is providing instructions to the parent of a child with iron-deficiency anemia about the administration of a liquid oral iron supplement. Which statement, if made by the parent, indicates an understanding of the administration of this medication? "I would give the iron with food." "I can mix the iron with cereal to give it." "I would add the iron to the formula in the baby's bottle." "I need to use a medicine dropper and place the iron near the back of the throat."
"I need to use a medicine dropper and place the iron near the back of the throat." Rationale: An oral iron supplement needs to be administered through a straw or a medicine dropper placed at the back of the mouth because it will stain the teeth. The parents need to be instructed to brush or wipe the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acidic environment to facilitate its absorption in the duodenum.
A nurse has provided discharge instructions to a client being placed on long-term anticoagulant therapy with warfarin sodium. Adequate learning would be evident if the client makes which statements? Select all that apply. "I may take over-the-counter medications as needed." "I will inform my dentist that I am taking this medication." "I need to alternate the timing of my daily dose of this medication." "I need to use a firm-bristled toothbrush to prevent the side effects of this medication." "I will have my blood levels checked as prescribed by my primary health care provider (PHCP)." "I will report any signs of blood in my urine or stool to my primary health care provider (PHCP)."
"I will inform my dentist that I am taking this medication." "I will have my blood levels checked as prescribed by my primary health care provider (PHCP)." "I will report any signs of blood in my urine or stool to my primary health care provider (PHCP)." Rationale: Clients need to notify all primary health care providers (PHCPs) that they are on warfarin sodium therapy. Dental procedures may put the client at risk for increased bleeding, so this would direct you to option 2. Knowing that the effectiveness of warfarin sodium is based on maintaining a therapeutic blood level will direct you to select option 5. Awareness of bleeding as a primary complication will direct you to option 6.
A nurse caring for a 23-year-old client newly diagnosed with type 1 diabetes mellitus teaches the client insulin administration. Which statement by the client indicates a need for further teaching? "It is not necessary for me to aspirate before injecting my insulin." "I will rotate my insulin injection between my arms, thighs, and abdomen on a daily basis." "I will perform a capillary blood glucose measurement before I administer my insulin regimen." "My glargine insulin is long acting and should be administered once a day, but insulin lispro is given just before I eat."
"I will rotate my insulin injection between my arms, thighs, and abdomen on a daily basis." Rationale: Rotation of insulin injections should be done within one anatomical site to maintain consistent absorption of insulin. The remaining options are correct statements regarding insulin administration and thus do not indicate a need for additional client teaching.
A neurologist prescribed ticlopidine to the client with thrombotic stroke. The nurse provides instructions to the client and spouse regarding the medication. Which statement made by the client indicates that education was effective? "I'll take the medicine with meals." "If I do not feel well, I should skip the medication." "I won't have another stroke if I take this medicine faithfully." "If I have any gastrointestinal side effects, I should call the neurologist."
"I'll take the medicine with meals." Rationale: Ticlopidine is an antiplatelet agent that is used to assist in preventing a thrombotic stroke. Ticlopidine is best tolerated when taken with meals. The most common side effects are gastrointestinal (GI) disturbances. Taking ticlopidine with meals tends to lessen those effects. It is not necessary to contact the neurologist or prescribing provider if GI upset occurs. The client would not skip medications. The medication is used to prevent strokes but does not guarantee that a stroke will not occur.
A client is prescribed nicotinic acid for the treatment of coronary artery disease and hyperlipidemia, and the nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions? "It is not necessary to avoid the use of alcohol." "The medication needs to be taken with meals to decrease flushing." "Clay-colored stools are a common side effect and would not be of concern." "Ibuprofen IB taken 30 minutes before the nicotinic acid would decrease the flushing."
"Ibuprofen IB taken 30 minutes before the nicotinic acid would decrease the flushing." Rationale: Flushing is an adverse effect of this medication. Aspirin or a nonsteroidal anti-inflammatory drug can be taken 30 minutes prior to taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this effect. The medication needs to be taken with meals to decrease gastrointestinal upset; however, taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and would be reported to the primary health care provider (PHCP) immediately.
The nurse provides instructions to the client about nicotinic acid prescribed for hyperlipidemia. Which statement by the client indicates understanding of the instructions? "The medication needs to be taken with meals to decrease flushing." "I don't need to stop drinking alcohol when taking nicotinic acid." "Clay-colored stools are a common side effect and are not a concern." "Ibuprofen taken 30 minutes before the nicotinic acid may decrease the flushing."
"Ibuprofen taken 30 minutes before the nicotinic acid may decrease the flushing." Rationale: Flushing is an adverse effect of this medication. Aspirin or a nonsteroidal antiinflammatory drug, as prescribed, can be taken 30 minutes prior to taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this effect. The medication needs to be taken with meals to decrease gastrointestinal upset; however, taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and need to be reported to the primary health care provider (PHCP) immediately.
The diabetes nurse specialist conducts a teaching session to a group of nursing students regarding sulfonylureas, oral hypoglycemic medications used for type 2 diabetes mellitus. Which statement, describing the primary action of these medications, would the nurse include in the teaching session? "Sulfonylureas decrease insulin resistance." "Sulfonylureas inhibit carbohydrate digestion." "Sulfonylureas decrease glucose production by the liver." "Sulfonylureas promote insulin secretion by the pancreas."
"Sulfonylureas promote insulin secretion by the pancreas." Rationale: Sulfonylureas promote insulin secretion by the pancreas and may also increase tissue response to insulin. Thiazolidinediones decrease insulin resistance. α-Glucosidase inhibitors inhibit carbohydrate digestion. Biguanides decrease glucose production by the liver.
The nurse is providing discharge instructions to a client taking warfarin sodium. Which statement, based on primary health care provider (PHCP) permission, is appropriate to include in client teaching for this medication? "Alcohol can be consumed as long as it is in small amounts." "You need to check with your doctor about what can be taken for headaches." "It doesn't matter what time the daily dose is taken as long as it is taken each day." "It is all right to take over-the-counter medications as long as they do not contain vitamin K."
"You need to check with your doctor about what can be taken for headaches." Rationale: Warfarin sodium is an anticoagulant that prevents further extension of formed existing clots and also prevents new clot formation and secondary thromboembolic complications. Because the medication places the client at risk for bleeding, the client is instructed to avoid salicylates (acetylsalicylic acid, or aspirin) and alcohol. The medication would be taken exactly as prescribed and at the same time daily. The client needs to avoid all over-the-counter medications and needs to consult with the PHCP before taking any other medications because of the risk for medication interactions.
A client with diabetes mellitus is self-administering NPH insulin from a vial that is kept at room temperature. The client asks the nurse about the length of time an unrefrigerated vial of insulin will maintain its potency. What is the most appropriate response to the client? 2 weeks 1 month 2 months 6 months
1 month Rationale: An insulin vial in current use can be kept at room temperature for up to 1 month without significant loss of activity. Direct sunlight and heat must be avoided.
The nurse monitors the blood glucose level of the client who received NPH insulin at 7:00 a.m. with an understanding that the client may experience a hypoglycemic reaction during which time frame? 9:00 a.m. to 11:00 a.m. 11:00 a.m. to 7:00 p.m. 7:00 p.m. to 11:00 p.m. Midnight to 6:00 a.m.
11:00 a.m. to 7:00 p.m. Rationale: NPH insulin is an intermediate-acting insulin. It peaks in 4 to 12 hours after administration. (Its onset is in 1.5 hours, and its duration is 16 to 24+ hours.) If the medication was given at 7:00 a.m., the nurse would monitor for hypoglycemia during the time of peak action, which would be between 11:00 a.m. and 7:00 p.m.
A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time would the nurse plan to assess the client for a hypoglycemic reaction? 10:00 11:00 17:00 24:00
17:00 Rationale: Humulin N is an intermediate-acting insulin. The onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and the duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.
The nurse is reviewing the laboratory results for a client who arrives at the health care clinic for follow-up assessment after being diagnosed with atrial fibrillation. The international normalized ratio (INR) is analyzed because the client has been taking warfarin sodium since discharge from the hospital. The nurse determines that the INR range is at an appropriate level if what value is noted on the laboratory report? 0.6 0.75 1.0 2.3
2.3 Rationale: The recommended INR range for warfarin sodium therapy for atrial fibrillation is 2.0 to 3.0 (2.0 to 3.0). Subtherapeutic INRs increase the client's risk for thrombus formation. The normal range for INR is 0.81 to 1.2 (0.81 to 1.2), so option 4 is therapeutic for this client.
The nurse is monitoring the laboratory test results for a client who is taking warfarin sodium after mechanical heart valve replacement. The nurse would expect the international normalized ratio (INR) for this client to be at what value in order to be therapeutic? 0.2 0.5 1.0 3.0
3.0 Rationale: The normal value for INR is 0.81 to 1.2 (0.81 to 1.2). The target INR or therapeutic level for a client receiving warfarin sodium is 2.5 to 3.5 (2.5 to 3.5).
A hospitalized client with diabetes mellitus receives NPH insulin in the morning. The nurse monitors the client for hypoglycemia, knowing that the peak action is expected to occur how soon after the medication administration? 2 to 4 hours after administration 4 to 12 hours after administration 12 to 16 hours after administration 18 to 24 hours after administration
4 to 12 hours after administration Rationale: NPH insulin is an intermediate-acting insulin. Its onset of action is 3 to 4 hours, it peaks in 4 to 12 hours, and its duration of action is 16 to 20 hours.
The nurse administers 20 units of insulin isophane recombinant to a hospitalized client with diabetes mellitus at 7:00 a.m. The nurse would monitor the client most closely for a hypoglycemic reaction at which time? 4:00 p.m. 9:00 a.m. 10:00 a.m. 12:00 midnight
4:00 p.m. Rationale: Insulin isophane recombinant is an intermediate-acting insulin with an onset of action in 3 to 4 hours, a peak action in 6 to 12 hours, and a duration of action of 18 to 28 hours. A hypoglycemic reaction is most likely to occur at peak time. The correct option is the only one that represents a time within the peak hours after administration of the insulin.
The nurse is monitoring a client receiving glipizide. The nurse knows that which finding would indicate a therapeutic outcome for this client? A decrease in polyuria An increase in appetite A glycosylated hemoglobin of 10% A fasting blood glucose of 220 mg/dL (12.6 mmol/L)
A decrease in polyuria Rationale: Glipizide is an oral hypoglycemic agent given to reduce the serum glucose level and the signs and symptoms of hyperglycemia. Therefore, a decrease in polyuria (a symptom of hyperglycemia) would denote a beneficial response to glipizide. Excessive appetite (polyphagia) also is a symptom of hyperglycemia. Thus, an increase in appetite would not signify a therapeutic effect. A therapeutic fasting blood glucose would be less than 100 mg/dL, and the glycosylated hemoglobin needs to be less than 7%.
A client receiving therapy with carbidopa/levodopa is upset and tells the home health nurse that the urine has turned a darker color since starting this medication. The client wants to discontinue its use. In formulating a response to the client's concerns, the nurse interprets that this change is indicative of which condition? Developing toxicity A harmless side effect of the medication A result of taking the medication with milk A sign of interaction with another medication
A harmless side effect of the medication Rationale: With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client would be reassured that this is a harmless effect of the medication, and its use should be continued. Darkened urine is not indicative of carbidopa/levodopa toxicity, the result of taking the medication with milk, or a sign of interaction with another medication.
A nurse is providing teaching regarding acarbose. The nurse would tell the client that which expected side or adverse effect(s) may occur with this medication? Tachycardia and dizziness Hypoglycemia and diaphoresis Tinnitus and decreased hearing Abdominal distention and diarrhea
Abdominal distention and diarrhea Rationale: Acarbose delays absorption of dietary carbohydrates and thereby reduces the rise in blood glucose after a meal. Its activity in the bowel promotes flatulence, cramping, and diarrhea. Acarbose does not have an effect on the heart. It may cause hypoglycemia and possibly associated diaphoresis, but this is not an expected side effect. Tinnitus and decreased hearing are side effects of aminoglycosides.
A client is taking ticlopidine hydrochloride. The nurse would tell the client to avoid which substance while taking this medication? Vitamin C Vitamin D Acetaminophen Acetylsalicylic acid
Acetylsalicylic acid Rationale: Ticlopidine hydrochloride is a platelet aggregation inhibitor. It is used to decrease the risk of thrombotic stroke in clients with precursor symptoms. Because it is an antiplatelet agent, other medications that precipitate or aggravate bleeding would be avoided during its use. Therefore, aspirin or any aspirin-containing product needs to be avoided. The substances in options 1, 2, and 3 are safe to consume.
The nurse is caring for a postpartum client with a diagnosis of deep vein thrombosis who is receiving a continuous intravenous infusion of heparin sodium. Review of which laboratory result is the most important by the nurse? Platelet count Prothrombin time (PT) International normalized ratio (INR) Activated partial thromboplastin time (aPTT)
Activated partial thromboplastin time (aPTT) Rationale: Anticoagulation therapy may be used to prevent the extension of thrombus by delaying the clotting time of the blood. The aPTT time needs to be monitored, and the heparin sodium dose would be adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control value in seconds. The platelet count cannot be used to determine an adequate dosage for the heparin sodium infusion. The PT and the INR are used to monitor coagulation time when warfarin sodium is used.
A client with diabetes mellitus taking daily NPH insulin has been started on therapy with dexamethasone. The nurse anticipates that which adjustments in medication dosage will be made? An increased dose of NPH insulin A change to oral diabetic medications A lower dose of dexamethasone than usual An increase in the amount of daily dietary calories
An increased dose of NPH insulin Rationale: Dexamethasone is a glucocorticoid (corticosteroid) and therefore can elevate the blood glucose level. Diabetic clients may need their dosage of insulin or oral hypoglycemic medications increased during glucocorticoid therapy. This is most often a temporary change, needed to compensate for the actions of the medication. The client would not change to an oral diabetic medication if taking daily insulin. Additional calories would not be required. The client would not take a lower dose of dexamethasone than usual to compensate.
Glyburide is prescribed for a client with type 2 diabetes mellitus. What is the most important instruction the nurse would provide to the client? Monitor for signs of infection. Weigh self daily. Assess for signs of hypoglycemia. Observe for lower extremity edema
Assess for signs of hypoglycemia. Rationale: Glyburide is a sulfonylurea that acts primarily by stimulating the release of insulin from pancreatic islets. It causes a dose-dependent reduction in blood glucose and can thereby cause hypoglycemia. Importantly, regardless of what the glucose level is—high, normal, or low—sulfonylureas will lead to a low blood glucose level. If the level is high, reducing it will be therapeutic. However, if the level is normal, reducing it will cause mild hypoglycemia. If the level is already low, reducing it can cause severe hypoglycemia. The correct option is 3. Option 1 is incorrect, as infections are not a side or adverse effect of sulfonylureas. Option 2 is incorrect; although weight gain is associated with sulfonylureas, it is not the most important instruction. Option 4 is incorrect, as edema is an adverse effect of thiazolidinediones, not sulfonylureas.
Insulin glargine is prescribed for a client with diabetes mellitus. The nurse would tell the client that it is best to take the insulin at which time? At bedtime every day 1 hour after each meal 15 minutes before the morning and evening meals Before each meal, on the basis of the blood glucose level
At bedtime every day Rationale: Insulin glargine is a long-acting recombinant DNA human insulin that is used to treat type 1 and type 2 diabetes mellitus. It has a 24-hour duration of action and is administered once a day at the same time, usually at bedtime. The
A client is scheduled to have heparin sodium 5000 units subcutaneously. What is the most appropriate nursing intervention? Inject via an infusion device. Inject ½ inch (1.25 cm) from the umbilicus. Massage the injection site after administration. Avoid aspirating prior to injecting the medication.
Avoid aspirating prior to injecting the medication. Rationale: Aspiration would be avoided before injecting the heparin because it can cause a hematoma at the administration site. Heparin sodium administered subcutaneously does not require an infusion device and is injected at least 2 inches (5 cm) from the umbilicus or any scar tissue. The needle is withdrawn rapidly, and the site is not massaged (although pressure is applied).
A home care nurse is visiting a client who was discharged to home with a prescription for continued administration of enoxaparin subcutaneously. What is the nurse's priority assessment for this client? Constipation Fear of needles Nausea or vomiting Bleeding gums or bruising
Bleeding gums or bruising Rationale: Enoxaparin is an anticoagulant. An adverse effect of anticoagulant therapy is bleeding. Accordingly, the nurse questions the client about signs and symptoms that could indicate bleeding, such as bleeding gums, bruising, hematuria, or dark, tarry stools.
A client began taking amantadine approximately 2 weeks ago. The client reports to the clinic for a follow-up evaluation. The nurse determines that the client is experiencing a side or adverse effect related to the use of this medication if which is noted? Decreased rigidity Decreased akinesia A blood pressure of 118/74 mm Hg Client complaints of urinary retention
Client complaints of urinary retention Rationale: Amantadine is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Leukopenia, urinary retention, and hypotension are all side and adverse effects of the medication.
A client with chronic kidney disease is receiving ferrous sulfate. The nurse instructs the client that which finding is a common side/adverse effect associated with this medication? Fatigue Headache Weakness Constipation
Constipation Rationale: Ferrous sulfate is an iron supplement used to treat anemia. Constipation is a frequent and uncomfortable side effect associated with the administration of oral iron supplements. Stool softeners often are prescribed to prevent constipation. Options 1, 2, and 3 are not side or adverse effects associated with this medication.
A client began taking amantadine approximately 2 weeks ago. The nurse determines that the medication is having a therapeutic effect if the client exhibits which finding? Decreased voiding Decreased blood pressure Decreased rigidity and akinesia Decreased white blood cell count
Decreased rigidity and akinesia Rationale: Amantadine is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Urinary retention, hypotension, and leukopenia are adverse effects of the medication.
The nurse is caring for a client who was just admitted to the hospital for the treatment of iron overload. The nurse anticipates that the primary health care provider will prescribe which medication to treat the iron overload? Terbinafine Granisetron Ketoconazole Deferoxamine
Deferoxamine Rationale: Deferoxamine is a medication used to treat iron overload. Granisetron is an antiemetic. Ketoconazole and terbinafine are antifungal medications.
A client is prescribed a liquid iron preparation that has the potential to stain the teeth. The nurse would instruct the client to take which action to prevent staining of the teeth? Brush the teeth before drinking the iron. Drink the iron undiluted for maximal effect. Dilute more than the amount prescribed to obtain the correct dosage. Dilute the iron in juice, drink it through a straw, and rinse the mouth afterward.
Dilute the iron in juice, drink it through a straw, and rinse the mouth afterward. Rationale: Liquid iron preparations will stain the teeth. The best advice for the client who needs liquid iron is to dilute the iron in juice or water, drink it through a straw, and rinse the mouth well afterward. Brushing before taking the liquid iron would not be of any benefit. The nurse would not instruct a client to take more than the prescribed amount.
The nurse is preparing to administer an intravenous (IV) insulin injection. The vial of regular insulin has been refrigerated. On inspection of the vial, the nurse finds that the medication is frozen. Which would the nurse do? Discard the insulin and obtain another vial. Wait for the insulin to thaw at room temperature. Check the temperature settings of the refrigerator. Rotate the vial between the hands until the medication becomes liquid.
Discard the insulin and obtain another vial. Rationale: Insulin would not be frozen. If the nurse notes that the vial of insulin is frozen, the insulin is discarded and a new vial is obtained. The remaining options are incorrect actions.
The nurse is preparing the client's morning insulin isophane dose. The nurse notices a clumpy precipitate inside the insulin vial. What is the mostappropriate nursing action related to this finding? Draw the dose from a new vial. Draw up and administer the dose. Shake the vial in an attempt to disperse the clump. Warm the vial under running water to dissolve the clump.
Draw the dose from a new vial. Rationale: The nurse would always inspect the vial of insulin before use for changes that may signify loss of potency. Insulin isophane normally is uniformly cloudy. Clumping, frosting, and precipitates are signs of insulin damage. In this situation, because potency is questionable, it is safer to discard the vial and draw up the dose from a new vial. Therefore, the remaining options are incorrect.
The primary health care provider has prescribed regular insulin 6 units and NPH insulin 20 units subcutaneously to be administered every morning for a client diagnosed with diabetes mellitus. How would the nurse prepare to administer insulin? Shake the NPH insulin vial to distribute the suspension. Administer regular insulin and NPH insulin in separate syringes. Draw up the regular insulin first and then the NPH insulin in the same syringe. Draw up the NPH insulin first and then the regular insulin in the same syringe.
Draw up the regular insulin first and then the NPH insulin in the same syringe. Rationale: Regular insulin is always drawn up before NPH insulin, and NPH insulin can be drawn into the same syringe as the regular insulin. Insulins usually are administered 15 to 30 minutes before a meal. To mix the NPH insulin suspension, the vial would be rotated gently. Shaking introduces air bubbles into the solution.
The nurse is preparing a dose of 10 units of regular insulin and 35 units of NPH insulin for a client with type 1 diabetes mellitus. The nurse obtains an insulin syringe, gently rotates the insulin solutions, cleans the tops of the vials of insulin, and injects an amount of air equal to the dose prescribed into each vial. What is the next nursing action? Draws up 10 units of regular insulin and checks the syringe contents with another nurse before drawing up the NPH insulin Draws up 10 units of regular insulin, draws up 35 units of NPH insulin, and checks the syringe contents with another nurse Draws up 35 units of NPH insulin and checks the syringe contents with another nurse before drawing up the regular insulin Draws up 35 units of NPH insulin, draws up 10 units of regular insulin, and checks the syringe contents with another nurse
Draws up 10 units of regular insulin and checks the syringe contents with another nurse before drawing up the NPH insulin Rationale: Insulin dosages are verified by another nurse before administration. When two types of insulins are mixed, the doses must be verified after each is drawn up so as to verify the dosage for each one. The regular insulin is drawn into the syringe first.
A client is receiving heparin sodium by continuous intravenous (IV) infusion. The nurse would notify the primary health care provider if ongoing nursing assessment reveals which finding? Tinnitus Ecchymosis Increased pulse rate Increased blood pressure
Ecchymosis Rationale: The client who receives a continuous IV infusion of heparin sodium is at risk for bleeding. The nurse assesses for signs/symptoms of bleeding, which include bleeding from the gums, ecchymosis on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The other options are not side or adverse effects related to this medication.
Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse would include in the client's teaching plan? Weight gain Hypoglycemia Flushing and palpitations Gastrointestinal disturbances
Gastrointestinal disturbances Rationale: The most common side effect of metformin is gastrointestinal disturbances, including decreased appetite, nausea, and diarrhea. These generally subside over time. This medication does not cause weight gain; clients lose an average of 7 to 8 lb (3.2 to 3.6 kg) because the medication causes nausea and decreased appetite. Although hypoglycemia can occur, it is not the most common side effect. Flushing and palpitations are not specifically associated with this medication.
A client newly diagnosed with diabetes mellitus is instructed by the primary health care provider to obtain glucagon for emergency home use. The client asks the home care nurse about the purpose of the medication. The nurse would instruct the client that the purpose of the medication is to treat which problem? Lipoatrophy from insulin injections Hypoglycemia from insulin overdose Hyperglycemia from insufficient insulin Lipohypertrophy from inadequate insulin absorption
Hypoglycemia from insulin overdose Rationale: Glucagon is used to treat hypoglycemia resulting from insulin overdose. The family of the client is instructed in how to administer the medication. In an unconscious client, arousal usually occurs within 20 minutes of glucagon injection. Once consciousness has been regained, oral carbohydrates would be given. Lipoatrophy and lipohypertrophy result from insulin injections.
The nurse evaluates that the family of a client newly diagnosed with diabetes mellitus correctly understands the reason for having glucagon on hand for emergency home use if the family indicates that the purpose of the medication is to treat which complication? Diabetic ketoacidosis Hypoglycemia from insulin overdose Hyperglycemia from overeating at meals Hyperglycemia occurring on "sick days"
Hypoglycemia from insulin overdose Rationale: Glucagon is used to treat hypoglycemia resulting from insulin overdose. The family of the client is instructed in how to administer the medication. In an unconscious client, consciousness usually returns within 20 minutes of glucagon injection. After the client has regained consciousness, oral carbohydrates would be given. The other options are incorrect.
A client is taking Humulin NPH insulin and regular insulin every morning. The nurse would provide which instructions to the client? Select all that apply. Hypoglycemia may be experienced before dinnertime. The insulin dose needs to be decreased if illness occurs. The insulin needs to be administered at room temperature. The insulin vial needs to be shaken vigorously to break up the precipitates. The NPH insulin needs to be drawn into the syringe first, then the regular insulin.
Hypoglycemia may be experienced before dinnertime. The insulin needs to be administered at room temperature. Rationale: Humulin NPH is an intermediate-acting insulin. The onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and its duration of action is 16 to 24 hours. Regular insulin is a short-acting insulin. Depending on the type, the onset of action is 30 to 60 minutes, it peaks in 1 to 5 hours, and its duration is 6 to 10 hours. Hypoglycemic reactions most likely occur during peak time. Insulin would be at room temperature when administered. Clients may need their insulin dosages increased during times of illness. Insulin vials would never be shaken vigorously. Regular insulin is always drawn up before NPH.
Insulin lispro is prescribed for the client with diabetes mellitus, and the client is instructed to administer the insulin before meals. When would the nurse instruct the client to administer the insulin? 45 minutes before eating 60 minutes before eating 90 minutes before eating Immediately before eating
Immediately before eating Rationale: Insulin lispro acts more rapidly than regular insulin and has a shorter duration of action. The effect of insulin lispro begins within 25 minutes after subcutaneous injection, peaks in 0.5 to 1.5 hours, and has a duration of action of approximately 5 hours. Because of its rapid onset, it can be administered from 15 minutes to immediately before eating. In contrast, regular insulin is generally administered 30 minutes before meals.
Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? Pruritus Tachycardia Hypertension Impaired voluntary movements
Impaired voluntary movements Rationale: Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.
The nurse is completing a health history for an insulin-dependent client who has been self-administering insulin for 40 years. The client reports experiencing periods of hypoglycemia followed by periods of hyperglycemia. What is the most likely cause for this pattern of blood glucose fluctuation? Eating snacks between meals Initiating the use of the insulin pump Injecting insulin at a site of lipodystrophy Adjusting insulin according to blood glucose levels
Injecting insulin at a site of lipodystrophy Rationale: Tissue hypertrophy (lipodystrophy) involves thickening of the subcutaneous tissue at the injection sites. This dense tissue can interfere with the absorption of insulin, resulting in erratic blood glucose levels. Because the client has been on insulin for many years, this is the most likely cause of poor control. The remaining options are appropriate for use in regulating blood glucose levels.
Sodium hypochlorite solution is prescribed for a client with a wound on the left foot that is draining purulent material. Which action would the nurse plan to take? Irrigate the wound with the solution. Soak the foot in the solution for 20 minutes daily. Place the solution in the wound, and cover with an occlusive dressing. Soak a sterile dressing with the solution, and pack the dressing into the wound.
Irrigate the wound with the solution. Rationale: Sodium hypochlorite is a solution that is used for irrigating and cleaning necrotic or purulent wounds. It can be used for packing necrotic wounds but cannot be used to pack purulent wounds because the solution is inactivated by copious pus. It needs to not come into contact with healing or normal tissue, and it would be rinsed off immediately if used for irrigation.
A client with a history of type 2 diabetes is admitted to the hospital with chest pain and scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? Glipizide Metformin Repaglinide Regular insulin
Metformin Rationale: Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld before and after cardiac catheterization
The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client recently admitted to the hospital and notes that the PHCP has prescribed ticlopidine therapy. Which finding on the client's record would indicate a need to contact the PHCP before initiating the medication prescription? Neutropenia Client history of stroke Client history of hypertension Complaints of gastrointestinal disturbances
Neutropenia Rationale: Neutropenia, or agranulocytosis, is the most serious adverse effect associated with the use of ticlopidine. A baseline complete blood cell (CBC) count with differential will be performed for the client. Neutropenia occurs most often within the first 3 months of therapy; therefore, a CBC with differential is recommended every 2 weeks during the first 3 months. If a diagnosis of neutropenia is determined, the client will be withdrawn from therapy. This medication is used to prevent a stroke and is not contraindicated in hypertension. Gastrointestinal disturbances can occur as a result of taking the medication, and the client is instructed to take the medication with food to minimize these side effects.
The nurse in a long-term care facility is reviewing the primary health care provider's (PHCP's) prescriptions on an assigned client. The nurse notes that the PHCP prescribed ropinirole hydrochloride. The nurse determines that this medication has been prescribed to treat which condition in the client? Depression Diabetes mellitus Coronary artery disease Parkinsonian syndrome
Parkinsonian syndrome Rationale: Ropinirole hydrochloride is a medication that is used to treat idiopathic parkinsonian syndrome. It normally is administered 3 times a day to treat the client. This medication is not used to treat depression, diabetes mellitus, or coronary artery disease.
The nurse is caring for a client who is receiving heparin sodium intravenously as a continuous infusion. Which laboratory finding requires immediate nursing intervention? Platelet count of 98,000 mm3 (98 × 109/L) Red blood cell count of 4.2 cells (4.2 × 1012/L) International normalized ratio (INR) of 1.2 Activated partial thromboplastin time (aPTT) of 60 seconds
Platelet count of 98,000 mm3 (98 × 109/L) Rationale: The platelet count indicates that the client receiving heparin sodium is at risk for heparin-induced thrombocytopenia (HIT). HIT would be suspected whenever platelet counts fall below normal. If severe thrombocytopenia develops (platelet count less than 100,000 mm3 [100 × 109/L]), heparin sodium needs to be discontinued. The aPTT in option 4 represents an expected finding for intravenous heparin sodium therapy. Option 3 is not a value measured for heparin sodium therapy but is used to measure a response to warfarin sodium therapy, and the red blood cell count in option 2 is normal.
The nurse is preparing to ambulate a client with Parkinson's disease who has recently been started on levodopa/carbidopa. Before performing this activity with the client, the nurse would include which most important assessment in the client's plan of care? History of falls Use of assistive devices Postural (orthostatic) vital signs Degree of exhibited intention tremor
Postural (orthostatic) vital signs Rationale: Clients with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem is exacerbated with the introduction of levodopa/carbidopa, which also can cause postural hypotension and increase the client's risk for falls. Although knowledge of the client's use of assistive devices and history of falls is helpful, neither of these options is the most important element of the assessment, based on the wording of this question. Clients with Parkinson's disease generally have resting tremor, not intention tremor.
A client with previously well-controlled diabetes mellitus has had fasting blood glucose levels ranging from 180 to 200 mg/dL. The client takes glyburide 5 mg orally daily. In reviewing the client's medication list, the home health care nurse suspects that which newly added medications could be contributing to the elevated blood glucose levels? Prednisone Ranitidine Cimetidine Ciprofloxacin
Prednisone Rationale: Corticosteroids, thiazide diuretics, and lithium may decrease the effect of glyburide, thus causing hyperglycemia. The medications listed in the incorrect options increase the effect of glyburide, leading to hypoglycemia.
A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL (10.2 to 11.4 mmol/L). Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? Atenolol Prednisone Phenelzine Allopurinol
Prednisone Rationale: Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 1, a beta blocker, and option 3, a monoamine oxidase inhibitor, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral agents, which can lead to hypoglycemia.
Enoxaparin sodium is prescribed for a client after hip replacement surgery. Which medication would the nurse anticipate to administer in the event of enoxaparin sodium overdose Epinephrine Phytonadione Protamine sulfate Diphenhydramine
Protamine sulfate Rationale: Enoxaparin sodium is an anticoagulant. Accidental overdose of this medication may lead to bleeding complications. The antidote is protamine sulfate. Epinephrine is used to treat hypersensitivity reactions or acute bronchial asthma attacks and bronchospasms. Phytonadione is the antidote for warfarin sodium. Diphenhydramine is an antihistamine.
A client receiving heparin sodium by continuous intravenous (IV) infusion removes the tubing from the pump to change his hospital gown. The nurse is concerned that the client received a bolus of medication. After requesting a prescription for a stat partial thromboplastin time (PTT), the nurse would check for the availability of which medication in the medication cart? Enoxaparin Phytonadione Protamine sulfate Aminocaproic acid
Protamine sulfate Rationale: If the tubing is removed from an IV pump and the tubing is not clamped, the client will receive a bolus of the solution and the medication contained in the solution. The client who receives a bolus dose of heparin sodium is at risk for bleeding. If the results of the next PTT are extremely high, a dose of protamine sulfate, the antidote for heparin sodium, may be prescribed. Enoxaparin is an anticoagulant. Phytonadione is the antidote for warfarin sodium. Aminocaproic acid is an antifibrinolytic agent (inhibits clot breakdown).
The nurse is preparing to administer phytonadione to the client. Which laboratory value would the nurse monitor to evaluate the effectiveness of the medication? Prothrombin time Blood ammonia level Direct serum bilirubin Serum potassium level
Prothrombin time Rationale: Phytonadione is needed for adequate blood clotting. Therefore, checking the prothrombin time is necessary 24 hours after injection of this medication. Blood ammonia levels are assessed to determine the conversion of ammonia to urea that normally occurs in the liver. Bilirubin is a measurement of the ability of the liver to conjugate and excrete bilirubin. Serum potassium is an electrolyte and is not affected by the injection of phytonadione.
A client is being discharged to home with enoxaparin for short-term therapy. What would the nurse explain to the family about the medication action? Relieves joint pain Dissolves urinary calculi Stops progression of multiple sclerosis Reduces the risk of deep vein thrombosis
Reduces the risk of deep vein thrombosis Rationale: Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis and thromboembolism in clients at risk. It is not used to treat the conditions listed in options 1, 2, or 3.
The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse would tell the client to take which action? Freeze the insulin. Refrigerate the insulin. Store the insulin in a dark, dry place. Keep the insulin at room temperature.
Refrigerate the insulin. Rationale: Insulin in unopened vials needs to be stored under refrigeration until needed. Vials are not to be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Options 1, 3, and 4 are incorrect.
The emergency department nurse is caring for a client admitted with diabetic ketoacidosis. The physician prescribes intravenous (IV) insulin. The nurse plans to prepare which type of insulin for the client? Insulin glargine Regular insulin Insulin isophane 50% human insulin isophane/50% human insulin
Regular insulin Rationale: Regular insulin can be administered by the IV route. Insulin glargine is a long-acting insulin. Insulin isophane and 50% human insulin isophane/50% human insulin are intermediate-acting insulins.
A client is scheduled to take ticlopidine. The nurse plans to take which action before implementing this medication therapy? Take the client's blood pressure. Obtain a prothrombin time (PT). Take the client's apical heart rate. Review the results of the complete blood cell (CBC) count.
Review the results of the complete blood cell (CBC) count. Rationale: Ticlopidine is an antiplatelet agent that is used for the prevention of thrombotic stroke. Ticlopidine's effects last for the life of the platelet, 7 to 10 days. Ticlopidine also can cause neutropenia, which is an abnormally small number of mature white blood cells (WBCs). Baseline data from a CBC count are necessary before implementation of therapy, and the nurse would monitor for neutropenia during this medication therapy. If this adverse effect does occur, the primary health care provider is notified and therapy needs to be stopped. The effects of neutropenia are reversible within 1 to 3 weeks. Options 1, 2, and 3 are actions that are not specific to this medication therapy.
A nurse provides dietary instructions to a client who will be taking warfarin sodium. The nurse would tell the client to avoid which food item? Grapes Spinach Watermelon Cottage cheese
Spinach Rationale: Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of phytonadione, which is needed for clotting. When a client is taking an anticoagulant, foods high in phytonadione often are omitted from the diet. Phytonadione-rich foods include green leafy vegetables, fish, liver, coffee, and tea.
A client has a prescription to receive enoxaparin. The nurse would plan to administer this medication by which route? Oral Intravenous Intramuscular Subcutaneous
Subcutaneous Rationale: Enoxaparin is an anticoagulant that is administered by the subcutaneous route. It is used in preventing thromboembolism in selected clients at risk. It also may be administered by the client at home after hospital discharge with follow-up assessments by a home health nurse. It is not administered orally or by the intravenous or intramuscular routes.
A nurse is caring for a client recently diagnosed with type 2 diabetes mellitus who has been prescribed sustained-release glipizide. What is the most important point for the nurse to include in teaching this client about this medication? Take the medication at least 1 hour after eating. Make sure to take the medication every 12 hours. Take measures to prevent and treat hyperglycemia. Swallow the medication whole and never crush or chew it.
Swallow the medication whole and never crush or chew it. Rationale: Sustained-release glipizide is designed to be slowly absorbed in the gastrointestinal tract. Crushing or chewing the tablet alters absorption of the medication. It must be taken 30 minutes before eating because absorption is delayed by food. Hypoglycemia may occur when taking this medication, especially with insufficient caloric intake. Sustained-release glipizide has a duration of action of 24 hours and is taken once a day.
Acarbose is prescribed for a client diagnosed with type 2 diabetes mellitus. What would the nurse include in the client's instructions? Take the medication with the first bite of each meal. Do not take the medication if you have a urinary tract infection. Monitor for hypoglycemia and treat symptoms with 4 oz of fruit juice. Hold the medication at the time of iodine contrast dye study, and restart it 48 hours after.
Take the medication with the first bite of each meal Rationale: Acarbose is an alpha-glucosidase inhibitor that delays absorption of dietary carbohydrates by inhibiting the enzyme alpha-glucosidase, which breaks down complex carbohydrates. It therefore slows digestion of carbohydrates, which reduces the postprandial rise in blood glucose, and would be taken with the first bite of food with each meal (3 times a day). The alpha-glucosidase inhibitors are the only oral antidiabetic agents whose effects do not depend at all on the presence of insulin. All of the other oral agents act, at least in part, by increasing insulin secretion and/or decreasing insulin resistance. Option 2 is incorrect, as there is no contraindication to taking acarbose with a urinary tract infection. Urinary tract infections are an adverse effect of sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor. Option 3 is incorrect, as hypoglycemia is not likely to occur with acarbose alone but may develop when acarbose is combined with insulin or a sulfonylurea. If hypoglycemia develops for a client taking acarbose, simple glucose must be used for treatment. Foods such as fruit juice that contain sucrose, a disaccharide that must be broken down, cannot be used for oral therapy to treat hypoglycemia because the acarbose will impede its hydrolysis and thereby delay absorption. Option 4 is incorrect, as it is metformin, a biguanide medication, that would be held at the time of an iodine contrast dye study and restarted 48 hours after because of the risk of renal injury.
Acarbose is prescribed to treat a client with type 2 diabetes mellitus. Which instruction would the nurse provide when teaching the client about this medication? Take the medication at bedtime. Take the medication with the first bite of each regular meal. The medication will be used to treat symptoms of hypoglycemia. Headache and dizziness are the most common side effects of this medication.
Take the medication with the first bite of each regular meal. Rationale: Acarbose is an α-glucosidase inhibitor. Taken with the first bite of each major meal, acarbose delays absorption of ingested carbohydrates, decreasing postprandial hyperglycemia. It is not taken at bedtime. Abdominal pain and flatulence (not headache and dizziness) are the most common side effects of this medication.
A client is diagnosed with iron-deficiency anemia, and ferrous sulfate is prescribed. The nurse would tell the client that it would be best to take the medication with which food? Milk Boiled egg Tomato juice Pineapple juice
Tomato juice Rationale: Ferrous sulfate is an iron preparation, and the client is instructed to take the medication with orange juice or another vitamin C-containing product or a product high in ascorbic acid to increase the absorption of the iron. Among the options presented, tomato juice is highest in vitamin C and ascorbic acid. Milk and eggs inhibit absorption of iron.
A client is taking trihexyphenidyl hydrochloride. The nurse would assess for which side or adverse effect of this medication? Diarrhea Urinary retention Urinary incontinence Excessive perspiration
Urinary retention Rationale: Trihexyphenidyl is an anticholinergic medication used for the treatment of Parkinson's disease. Therefore, it can cause urinary hesitancy and retention, constipation, dry mouth, and decreased sweating.
The nurse is preparing to administer heparin sodium subcutaneously. Which nursing action is the most appropriate? Apply heat after the injection. Aspirate before injection of the medication. Use a 25- to 27-gauge, ½-inch (1.3 cm) needle. Use a 21- to 23-gauge, 1-inch (2.5 cm) needle.
Use a 25- to 27-gauge, ½-inch (1.3 cm) needle. Rationale: For subcutaneous heparin sodium injection, a 25- to 27-gauge, ½-inch (1.3 cm) needle is used to prevent tissue trauma and inadvertent intramuscular injection. The application of heat may affect the absorption of the heparin sodium and cause bleeding. A 1-inch (2.5 cm) needle would inject the heparin sodium into the muscle. Aspiration before injection is an incorrect technique with heparin sodium administration because it could cause bleeding in the tissues.
The nurse has a prescription to administer a dose of iron by the intramuscular route to the client with anemia. What are the most appropriate nursing actions? Select all that apply. Use a Z-track method. Administer the medication only in the deltoid. Aspirate for blood after the needle is inserted.Use an air lock when drawing up the medication. Change the needle after drawing up the dose and before injection. Massage the injection site well after injection to hasten absorption.
Use a Z-track method. Aspirate for blood after the needle is inserted. Use an air lock when drawing up the medication. Change the needle after drawing up the dose and before injection. Rationale: An air lock and a Z-track method are both used when administering iron by the intramuscular route. Proper technique includes changing the needle after drawing up the medication but before giving it to prevent staining of skin. After insertion of the needle, the nurse would aspirate for 5 to 10 seconds. If no blood returns with aspiration, the medication is injected slowly. The ventrogluteal site is the preferred site, and proper identification of appropriate landmarks is essential. The site would not be massaged after injection because massaging could cause staining of the skin.
The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? Withdraws the NPH insulin first Withdraws the regular insulin first Injects air into NPH insulin vial first Injects an amount of air equal to the desired dose of insulin into each vial
Withdraws the NPH insulin first Rationale: When preparing a mixture of short-acting insulin, such as regular insulin, with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3, and 4 identify correct actions for preparing NPH and short-acting insulin.
