NCLEX PassPoint - PN
The nurse is reinforcing teaching about aspirin therapy with a client diagnosed with transient ischemic attacks (TIA). Which statement made by the client indicates understanding? "I need to take aspirin regularly to prevent headaches." "If I take aspirin, I am less likely to develop a bleed in my brain." "Aspirin will help prevent me from having a stroke." "Taking aspirin regularly will reduce my risk of having severe pain."
"Aspirin will help prevent me from having a stroke." Explanation: Aspirin is taken prophylactically to prevent cerebral infarction secondary to embolism and thrombosis. Headache is not common in TIAs. Aspirin can increase the chances of intracranial hemorrhage, especially if the dose is excessive. Aspirin can help reduce specific types of pain, but will not reduce the risk of having severe pain
A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. The nurse includes which instruction in the discharge teaching? "You may take antacids with other medications." "Take antacids with meals." "Avoid taking antacids containing magnesium if you develop a heart problem." "Continue to take antacids, even if your symptoms subside."
"Continue to take antacids, even if your symptoms subside." Explanation: Antacids decrease gastric acidity and should be continued even if the client's symptoms subside. Because other medications may interfere with antacid action, the client should avoid taking antacids concomitantly with other drugs. If cardiac problems arise, the client should avoid antacids containing sodium, not magnesium. For optimal results, the client should take an antacid 1 hour before or 2 hours after meals.
A nurse is reinforcing education for a client who has been prescribed buspirone for long-term treatment of anxiety. The nurse determines that the education has been effective when which statement is made by the client? "I will take the medicine only when I feel an anxiety attack coming on." "I will not take the medicine with my meals." "I will not stop the medicine if I become pregnant." "I will not take the medicine with grapefruit juice."
"I will not take the medicine with grapefruit juice." Explanation: Clients who are taking buspirone should be instructed to avoid grapefruit juice. It can increase the effects of buspirone. Instruct clients to take buspirone with food to decrease nausea, to avoid during pregnancy, and to take on a regular basis—not "as needed."
The nurse is reinforcing discharge instructions to a client with chronic cholecystitis. Which response by the client indicates the education has been effective? "I will take my anticholinergic medications as prescribed." "I should increase the fat in my diet." "I need to rest more." "I should avoid taking antacids."
"I will take my anticholinergic medications as prescribed." Explanation: Conservative therapy for chronic cholecystitis includes weight reduction by increasing physical activity, a low-fat diet, antacid use to treat dyspepsia, and anticholinergic use to relax smooth muscles and reduce ductal tone and spasm, thereby reducing pain.
The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in a client with posttraumatic stress disorder (PTSD) can be demonstrated by which client self-report? "I'm sleeping better and don't have nightmares." "I'm not losing my temper as much." "I've lost my craving for alcohol." "I've lost my phobia of water."
"I'm sleeping better and don't have nightmares." Explanation: MAO inhibitors are used to treat sleep problems, nightmares, and intrusive daytime thoughts in individuals with PTSD. MAO inhibitors aren't used to help control temper or phobias or to decrease the craving for alcohol.
During the client-teaching session, which instruction should the nurse give to a client receiving alprazolam? "Discontinue the medication immediately if you experience nausea." "Notify the physician if you experience urine retention." "Apply sunscreen to prevent photosensitivity." "Inform the physician if you become pregnant or intend to do so."
"Inform the physician if you become pregnant or intend to do so." Explanation: Because alprazolam is contraindicated during pregnancy, the client should be instructed to inform the physician if she becomes pregnant. Nausea, urine retention, and photosensitivity are adverse reactions that may occur with alprazolam use, not contraindications.
A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? "Yes, it produces no adverse effects." "No, it can initiate premature uterine contractions." "No, it can promote sodium retention." "No, it can lead to increased absorption of fat-soluble vitamins."
"No, it can initiate premature uterine contractions." Explanation: Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it doesn't promote sodium retention. Castor oil isn't known to increase absorption of fat-soluble vitamins, although laxatives can decrease absorption if intestinal motility is increased.
The parents of a child with cystic fibrosis ask the nurse why their child must receive supplemental pancreatic enzymes. Which response by the nurse would be most appropriate? "Pancreatic enzymes promote absorption of nutrients and fat." "Pancreatic enzymes promote adequate rest." "Pancreatic enzymes prevent intestinal mucus accumulation." "Pancreatic enzymes help prevent meconium ileus."
"Pancreatic enzymes promote absorption of nutrients and fat." Explanation: Pancreatic enzymes are given to a child with cystic fibrosis to aid fat and protein digestion. They don't promote rest or prevent mucus accumulation or meconium ileus.
Treatment for a child with sinus bradycardia includes atropine 0.02 mg/kg. If the child weighs 20 kg, how much is given per dose? Record your answer using one decimal place.__________ mg
0.4 Explanation: Use the following equation:0.02 mg/kg × 20 kg = 0.4 mg
A client is prescribed heparin 6,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/1 mL. How many milliliter(s) of heparin should the nurse administer? Record your answer using one decimal place.
0.6 Explanation: The dose dispensed by the pharmacy is 10,000 units/1 mL, and the desired dose is 6,000 units. The nurse should use the following equations to determine the amount of heparin to administer: Dose on hand/quantity on hand = dose desired/X 10,000 units/1 mL = 6,000 units/X 10,000 units X X = 6,000 units X 1 mL X = 6,000 units X 1 mL/10,000 units X = 0.6 mL.
A client who takes over-the-counter drugs regularly is seen at a clinic. The nurse should take which actions to ascertain the client's safety when taking these drugs? Select all that apply. Determine whether the drugs are expensive Determine whether the drugs are generic Determine whether the client knows the appropriate drug dosages and administration schedules Determine whether the client knows that these drugs are available in the hospital Determine whether the client knows the correct reason for using the drug and its proper route of administration
1. Determine whether the client knows the appropriate drug dosages and administration schedules 2. Determine whether the client knows the correct reason for using the drug and its proper route of administration Explanation: The nurse should determine whether the client knows the appropriate dosages and administration schedules for any over-the-counter drugs taken regularly. The nurse also should determine whether the client knows the correct reason for using the drug and its proper route of administration. Neither the drug's cost nor its generic classification is as important unless a problem arises with either of these two factors. Availability of drugs in the hospital isn't a high-priority issue unless the client wants to purchase them from an outpatient pharmacy.
The physician prescribes an infusion of 2,400 ml of I.V. fluid over 24 hours, with half this amount to be infused over the first 10 hours. During the first 10 hours, the client should receive how many milliliters of I.V. fluid per hour? 50 ml/hour 100 ml/hour 120 ml/hour 240 ml/hour
120 ml/hour Explanation: First, the nurse determines how many milliliters (half of the total) to administer over the first 10 hours: 2,400 ml ÷ 2 = 1,200 ml. Then, the nurse determines how many of these milliliters to deliver per hour: 1,200 ml ÷ 10 hours = 120 ml/hour.
The client is to receive an I.V. infusion of 3,000 ml of dextrose and normal saline solution over 24 hours. The nurse observes that the rate on the infusion pump is set at 150 ml/hour. If the solution runs continuously at this rate, the infusion will be completed in: 12 hours. 20 hours. 24 hours. 50 hours.
20 hours. Explanation: The total amount to be given, 3,000 ml, divided by the hourly rate, 150 ml/hour, equals the length of the infusion or, in this case, 20 hours. Therefore, the I.V. infusion pump was set at the incorrect rate.
After a 3-month trial of dietary therapy, a client with type 2 diabetes still has blood glucose levels above 180 mg/dl. The physician adds glyburide, 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take glyburide: 30 minutes before breakfast. in the mid-morning. 30 minutes after dinner. at bedtime.
30 minutes before breakfast. Explanation: Like other oral antidiabetic agents prescribed in a single daily dose, glyburide should be taken at breakfast or 30 minutes before breakfast. If the client takes glyburide later, such as in the mid-morning, after dinner, or at bedtime, the drug won't provide adequate coverage for all meals consumed during the day.
The nurse is caring for a 12-month-old child with otitis media. The child weighs 11 kg and has no known drug allergies. The primary health care provider has prescribed amoxicillin 200 mg PO every 12 hours. The drug available is amoxicillin suspension 250 mg/5mL. What should the nurse administer per dose? Record your answer using a whole number. mL
4 Explanation: (5 mL/250 mg) x 200 mg/dose = 4 mL/dose.
A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion? 31 drops/minute 35 drops/minute 39 drops/minute 42 drops/minute
42 drops/minute Explanation: To determine the drip rate, set up the following equation:X drops/minute = 15 drops/1 ml × 1,000 ml/6 hours × 1 hour/60 minutesX = 15,000/360X = 41.6, or 42 drops/minute.
A toddler is ordered 350 mg of amoxicillin and clavulanate by mouth four times per day. The pharmacy sends a bottle with a concentration of 250 mg/5 ml. How many milliliters should the nurse administer per dose? Record your answer using a whole number.
7 Explanation: The following formula is used to calculate drug dosages: Dose on hand/Quantity on hand = Dose desired/X. In this example, the equation is 250 mg/5 ml = 350 mg/X. X = 7 ml.
A licensed practical nurse (LPN/LVN) is working with the RN in verifying a heparin IV infusion rate. The prescribed dose is 400 units of heparin per hour. The heparin is in a solution of 5,000 units/100 mL NS. How many milliliters per hour should the pump be set? Record your answer using a whole number.
8 Explanation: mL/hour = 100 mL/5,000 U x 400 U/1 hour = 8 mL/hr (Dimensional Analysis) 5,000 units divided by 100 mL NS = 50 units/mL. 400 units divided by 50 units/mL = 8 mL. 50 units of heparin in each milliliter of the solution; 8 mL/hour delivers 400 units.
When giving an intramuscular (IM) injection, which angle should the nurse insert the needle into the muscle? 15 degrees 30 degrees 45 degrees 90 degrees
90 degrees Explanation: When giving an IM injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when administering an intradermal injection. A 30-degree angle isn't used for any type of injection. A 45- or 90-degree angle can be used when giving a subcutaneous injection.
A school-age client reports pain. After rating the pain on an age-appropriate pain scale, the nurse determines that the client's pain is minor. Which of the following drugs should the nurse administer? Morphine Fentanyl Ibuprofen Acetaminophen
Acetaminophen Explanation: Acetaminophen, when used as directed, is safe even for neonates and has the benefit of helping to reduce fever in addition to relieving mild pain. Morphine, fentanyl, and ibuprofen aren't drugs of choice for treating mild pain in children. Morphine and fentanyl are reserved for severe pain.
x When drawing up a medication, the nurse notes there are small air bubbles adhering to the interior surface of the syringe. The nurse knows which effect the bubbles might have on parenteral administration? Altered onset of action Altered duration Altered drug absorption Altered drug dose
Altered drug dose Explanation: Although not harmful to the client when injected, small air bubbles can change the dose of medication actually administered; therefore, the nurse should remove the air bubbles. The drug's onset of action, duration, and absorption won't be affected. Air bubbles may actually be helpful in some situations but should be added only after the dose of the drug has been withdrawn accurately. For example, with iron dextran, an air bubble and the Z-track method of injection help prevent permanent staining of the client's skin if the solution leaks into the subcutaneous tissue.
The nurse monitors a client receiving enoxaparin, 30 mg subQ b.i.d after hip replacement surgery. Which adverse reaction is the client most likely to experience? Anaphylactic shock Hypersensitivity Bronchospasm Bleeding
Bleeding Explanation: Bleeding is the most common adverse reaction associated with enoxaparin. The drug isn't known to induce anaphylactic shock or bronchospasm, and hypersensitivity reactions are rare.
A client receiving antiplatelet therapy is being monitored for adverse reactions. For which most commonly produced adverse reaction would the nurse observe this client? Bleeding Difficulty hearing Confusion Agranulocytosis
Bleeding Explanation: Clients receiving antiplatelet agents usually develop bleeding due to the decrease responsiveness of platelets to clot. Difficulty hearing and confusion are adverse reactions associated with aspirin only. Agranulocytosis is associated with sulfinpyrazone (Anturane).
A client with a history of gout is admitted to the medical-surgical unit. The nurse should expect to administer which medication to a client with gout? Aspirin Furosemide Colchicine Calcium gluconate
Colchicine Explanation: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician prescribes colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin is used to reduce joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't used to treat gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate is used to reverse a negative calcium balance and relieve muscle cramps, not to treat gout.
When preparing to give a client a prescribed drug, the nurse realizes that the drug is one the nurse has never administered before. No drug references on the nursing unit contain information about the drug in question. What is the nurse's best action? Contact a pharmacist to obtain information about the drug. Consult the physician for information about the drug. Ask other nurses on the unit for information about the drug. Refuse to give the drug because no written information exists.
Contact a pharmacist to obtain information about the drug. Explanation: Pharmacists are the best resources for drug information when print sources aren't available, and they can provide this information quickly and reliably. Pharmacists have more up-to-date and accurate drug information than do physicians and other nurses. The nurse should refuse to give a drug only if no information about the drug is available.
Topical treatment with 2.5% hydrocortisone is prescribed for a 6-month-old infant with eczema. The nurse advises the parent to use the cream for no more than 1 week based on which rationale? Excessive use can have adverse effects, such as skin atrophy and fragility. If no improvement is seen after 1 week, an antibiotic will be prescribed. If no improvement is seen, a stronger concentration will be prescribed. The drug loses its efficacy after prolonged use.
Excessive use can have adverse effects, such as skin atrophy and fragility. Explanation: Hydrocortisone cream should be used for brief periods to decrease adverse effects such as atrophy of the skin. The drug does not lose efficacy after prolonged use. Astronger concentration may not be prescribed if no improvement is seen. An antibiotic would be inappropriate in this instance.
The nurse is caring for a 21 kg child with a urinary tract infection. The health care provider has ordered amoxicillin 750 mg by mouth every 8 hours. The recommended pediatric dosage is 40 to 90 mg/kg/day in two to three divided doses. Which action should the nurse take? Administer the medication in 4 ounces of juice. Do not begin the antibiotic therapy until the culture and sensitivity results are final. Hold the medication and notify the health care provider that the dose exceeds the recommended range. Administer the medication by injection if the child is uncooperative and refuses the oral medication.
Hold the medication and notify the health care provider that the dose exceeds the recommended range. Explanation: The nurse should notify the health care provider that the ordered dosage exceeds the recommended range for this child, which is 280 to 630 mg/dose.40 mg/kg/day × (1 day)/(3 doses) × 21 kg = 840 mg/3 doses = 280 mg/dose90 mg/kg/day × (1 day)/(3 doses) × 21 kg = 1,890 mg/3 doses = 630 mg/dose
A nurse is caring for a client who's taking the anticoagulant warfarin (Coumadin). Which instruction regarding warfarin therapy should the nurse give to the client? Report incidents of diarrhea. Limit foods high in vitamin K. Use a straight razor when shaving. Take aspirin for pain relief.
Limit foods high in vitamin K. Explanation: The client taking warfarin should avoid consuming large amounts of foods high in vitamin K because vitamin K can interfere with anticoagulation. The client may need to report diarrhea, but this symptom isn't an effect of taking an anticoagulant. An electric razor, not a straight razor, should be used to prevent cuts that cause bleeding. Because aspirin can increase the risk of bleeding, acetaminophen should be used for pain relief.
A male client is receiving digoxin and furosemide to treat heart failure. He reports feeling weak and having muscle cramps. His apical pulse is 76 beats/minute; respirations, 16 breaths/minute; and blood pressure, 148/86 mm Hg. What action should the nurse take? Tell the client that he's probably weak from inactivity. Look at the chart for his last potassium level and contact the physician. Look at the chart for his last digoxin level and notify the physician. Notify the physician that the client is experiencing heart failure.
Look at the chart for his last potassium level and contact the physician. Explanation: Muscle weakness and cramping are signs of hypokalemia, which can be an adverse effect of furosemide. If the nurse doesn't follow up on his complaints, the client's hypokalemia will worsen. The client isn't exhibiting symptoms indicative of digoxin toxicity or heart failure, so there's no need to notify the physician.
While shopping at a mall, a woman experiences an episode of extreme terror accompanied by anxiety, tachycardia, trembling, and fear of going crazy. A friend drives her to the emergency department, where a physician rules out physiological causes and refers her to the psychiatric resident on call. The nurse caring for this client would expect the health care practitioner to prescribe which medication to control the client's anxiety? Haloperidol Lorazepam Bupropion Paroxetine
Lorazepam Explanation: Lorazepam is a schedule IV drug used to treat anxiety. Reducing the client's anxiety will help her cope with stress. Haloperidol is an antipsychotic agent. Bupropion is an antidepressant. Paroxetine is a selective serotonin reuptake inhibitor used to treat depression.
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention would the nurse use to determine if TPN is providing adequate nutrition? Accelerating the infusion if it falls behind schedule Ensuring that the TPN tubing has an in-line filter Monitoring the client's weight every day Recording fluid intake and output
Monitoring the client's weight every day Explanation: By weighing the client every day, the nurse helps the team evaluate the client's response to TPN. Maintenance of the current weight is one indicator of adequate nutrition; weight loss may indicate inadequate nutrition, whereas weight gain may indicate adequate nutrition or fluid retention. The nurse shouldn't accelerate a TPN infusion that has fallen behind because this can cause wide fluctuations in the blood glucose level. Use of an in-line filter on TPN tubing traps bacteria and particles but has no effect on nutrition. The nurse records intake and output to evaluate fluid replacement — not the nutritional adequacy of TPN.
A client with chronic schizophrenia who takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, tachycardia, altered consciousness, and diaphoresis. These findings suggest which life-threatening reaction? Tardive dyskinesia Dystonia Neuroleptic malignant syndrome Akathisia
Neuroleptic malignant syndrome Explanation: The client's signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness.
When checking a client's medication profile, the nurse notes that the client is receiving a drug that is contraindicated in clients with glaucoma. The nurse knows that this client has a history of glaucoma and has been receiving the medication for the past 3 days. What should the nurse do first? Continue to give the medication because the client has been receiving it for 3 days. Report the information to the physician to ensure client safety. File an incident report because several other staff members gave the medication. Find out whether there are extenuating reasons for giving the drug to this client.
Report the information to the physician to ensure client safety. Explanation: The nurse should report the information to the physician because the client's safety may be endangered. The fact that the client has received the drug for several days doesn't guarantee that giving another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.
The nurse has an order to administer an intramuscular (I.M.) injection using the Z-track technique. When carrying out this order, what nursing intervention should the nurse implement? Insert the needle at a 45-degree angle. Wipe the needle immediately after injection. Pull the skin laterally toward the injection site. Simultaneously withdraw the needle and release the skin.
Simultaneously withdraw the needle and release the skin. Explanation: When giving an I.M. injection using the Z-track technique, the nurse pulls the skin laterally away from the injection site, inserts the needle at a 90-degree angle, waits 10 seconds after injecting the medication, and then simultaneously withdraws the needle and releases the skin.
The nurse is administering sublingual nitroglycerin to the client. Immediately after administration, the nurse observes the client for which possible sign or symptom? Nervousness or paresthesia Throbbing headache or dizziness Drowsiness or blurred vision Tinnitus or diplopia
Throbbing headache or dizziness Explanation: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia don't occur as a result of nitroglycerin therapy.
A client is prescribed fluphenazine hydrochloride, 10 mg by mouth daily in divided doses. The pharmacy sends liquid concentrate for the client because he has difficulty swallowing tablets. Which precaution should the nurse take when administering this medication? Wear gloves when preparing the solution and avoid having the drug contact the skin. Dilute the concentrate with apple juice. Have the client take the concentrate through a straw. Administer the drug with food.
Wear gloves when preparing the solution and avoid having the drug contact the skin. Explanation: Liquid and parenteral forms of fluphenazine hydrochloride can cause contact dermatitis. The nurse should wear gloves when preparing solutions and avoid having the drug contact the skin. The liquid concentrate should be diluted with water, fruit juice (except apple juice), milk, or semi-solid food just before administration. It isn't necessary for the client to take the concentrate through a straw. The drug can be administered without regard to food.
A 12-year-old child with cystic fibrosis (CF) is prescribed pancrealipase for a trypsin deficiency. When reinforcing education with the child and parents, how does the nurse instruct them to administer the pancrelipase? On an empty stomach Between meals With meals and snacks At bedtime
With meals and snacks Explanation: Trypsin is absent in more than 80%of children with CF. Pancreatic enzyme replacement is given with all meals and snacks to help digest food. Pancrelipase is an enteric-coated enzyme replacement that delays release of the enzyme and prevents its destruction in the acid environment of the stomach. Capsules may be swallowed whole or opened and sprinkled on a small quantity of cold or room-temperature food and swallowed or eaten immediately. When sprinkled on soft food, the contents of the capsules should be swallowed without chewing to avoid mucous membrane irritation. After swallowing the contents of the capsule, the child should drink a full glass of water or juice.
When conducting an information session for a group of clients with genital herpes which medication information should the nurse include? acyclovir penicillin doxycycline tetracycline
acyclovir Explanation: Acyclovir reduces symptoms of oral and genital herpes and reduces viral shedding and healing time. Penicillin is used to treat syphilis. Doxycycline and tetracycline are used to treat gonorrhea and syphilis in penicillin-allergic clients.
The nurse is caring for a 2-year-old child following surgery. The nurse is preparing to administer a dose of hydrocodone syrup to the child for postoperative pain. What should the nurse select to administer this drug? a teaspoon a clear, one ounce medicine cup a 3 mL syringe with the needle removed an oral syringe
an oral syringe Explanation: Oral medications should only be administered using oral syringes. The other options have the potential for inaccuracy and improper administration. Oral preparations have inadvertently been administered by injection when prepared in a parenteral syringe.
A client with long-standing rheumatoid arthritis has frequent reports of joint pain. The plan of care should be based on the understanding that chronic pain is most effectively relieved when analgesics are administered in which way? conservatively intramuscular on an as-needed basis at regularly scheduled intervals
at regularly scheduled intervals Explanation: To control chronic pain and prevent cycled pain, regularly scheduled intervals of analgesia administration are most effective. As-needed and conservative administration aren't effective means to manage chronic pain because the pain isn't relieved regularly. IM administration isn't practical on a long-term basis.
On discharge after treatment for alcoholism, a client plans to take disulfiram as prescribed. When teaching the client about this drug, the nurse emphasizes the need to: avoid all products containing alcohol. adhere to concomitant vitamin B therapy. return for monthly blood drug level monitoring. limit alcohol consumption to a moderate level.
avoid all products containing alcohol. Explanation: To avoid severe adverse effects, the client taking disulfiram must strictly avoid alcohol and all products that contain alcohol. Vitamin B therapy and blood monitoring aren't necessary during disulfiram therapy.
A client is admitted to the hospital displaying sinus bradycardia, nausea, anorexia, and blurred vision. What should the nurse suspect this client to be experiencing? digoxin toxicity myocardial infarction hypertensive crisis cor pulmonale
digoxin toxicity Explanation: Digoxin toxicity typically causes bradycardia, nausea, anorexia, and vision disturbances. Myocardial infarction, hypertensive crisis, and cor pulmonale usually do not cause vision disturbance.
A child with asthma is receiving theophylline. The nurse knows that theophylline is administered primarily to: decrease coughing induced by postnasal drip. dilate the bronchioles. reduce airway inflammation. eradicate the infection.
dilate the bronchioles. Explanation: Methylxanthines, such as theophylline, are highly potent bronchodilators used to relieve asthma symptoms. Antihistamines typically are used to relieve a cough induced by postnasal drip; corticosteroids, to reduce airway inflammation; and antibiotics, to treat infection.
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which data collected by the nurse suggests that the decongestant has been effective? clear nasal drainage increased tearing less sneezing headache
less sneezing Explanation: Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants dry the mucous membranes; therefore, nasal drainage should be decreased, and the client should not experience tearing. Because decongestants alleviate congestion, they also relieve headaches, which can be caused by congestion.
A 2-year-old child is being treated with rifampin for tuberculosis. Which finding does the nurse expect to find in the client? hyperactivity orange body secretions decreased bilirubin levels decreased levels of liver enzymes
orange body secretions Explanation: Rifampin and its metabolites will turn urine, feces, sputum, tears, and sweat an orange color. This is not a serious adverse effect. Rifampin may also cause GI upset, headache, drowsiness, dizziness, vision disturbances, and fever. Liver enzyme and bilirubin levels increase because of hepatic metabolism of the drug. Parents should be taught the signs and symptoms of hepatitis and hyperbilirubinemia, such as jaundice of the sclera or skin.
A pregnant client at term is in early labor. Over the past 12 hours, the client has been experiencing contractions every 10 to 12 minutes and has not progressed. The nurse would anticipate which medication as being prescribed to help stimulate uterine contractions? estrogen fetal cortisol oxytocin progesterone
oxytocin Explanation: Oxytocin is the hormone responsible for stimulating uterine contractions and may be given to clients to induce or augment uterine contractions. Although estrogen has a role in uterine contractions, it is not given to help uterine contractility. Fetal cortisol is believed to slow the production of progesterone by the placenta. Progesterone has a relaxing effect on the uterus.
Which finding indicates to the nurse that a client's peripherally placed intermittent infusion intravenous (IV) site is infected? puffiness of the tissue below the tip of the needle and absence of blood return a painful red line running down the arm along the course of the vein a tender lump within the vein located close to the tip of the needle redness and drainage around the insertion site of the needle
redness and drainage around the insertion site of the needle Explanation: Redness and drainage around the insertion site of a peripherally placed needle for intermittent infusion of antibiotics are cardinal signs of infection. Puffiness below the tip of the needle indicates infiltration of the IV. A painful red line running down the arm along the course of the vein indicates phlebitis. A lump located close to the tip of the needle may indicate a thrombus.
The nurse suspects that a 68-year-old client has digoxin toxicity. The nurse should assess for: hearing loss. vision changes. decreased urine output. gait instability.
vision changes. Explanation: Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.