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What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms?
- A. Take this medication with or without food
- B. Avoid using heat or ice on injured muscles while taking this medication
- C. Use cold and allergy medications only as directed by a healthcare provider
- D. Discontinue all nonsteroidal anti-inflammatory medications
Correct Answer: C
Rationale: The correct answer is C: 'Use cold and allergy medications only as directed by a healthcare provider.' It is essential to inform the client not to self-medicate with cold and allergy medications or make changes without consulting a healthcare provider to prevent potential drug interactions or adverse effects. Choice A is incorrect because cyclobenzaprine can be taken with or without food, so there is no specific requirement to take it on an empty stomach. Choice B is incorrect because using heat or ice on injured muscles while taking cyclobenzaprine is generally safe and can help with symptom management. Choice D is also incorrect because discontinuing nonsteroidal anti-inflammatory medications should be done under the guidance of a healthcare provider, but it is not a direct concern related to taking cyclobenzaprine for muscle spasms.
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When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse?
- A. Headache
- B. Pruritus
- C. Nausea
- D. Stridor
Correct Answer: D
Rationale: Stridor is a high-pitched, noisy breathing sound that can indicate a serious condition like airway obstruction or a severe allergic reaction, necessitating immediate intervention to maintain the client's airway and prevent further complications. While headache, pruritus, and nausea are important to assess and manage, they are not as immediately life-threatening as stridor, which requires prompt attention to prevent respiratory compromise.
A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?
- A. Discontinue the IO infusion
- B. Administer an analgesic via the IO site
- C. Elevate the extremity with the IO site
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct action for the nurse to take first is to discontinue the IO infusion. The client's symptoms of severe pain, numbness, pale skin, and edema below the IO site suggest a complication, such as extravasation or compartment syndrome. By discontinuing the infusion, further harm can be prevented. Administering an analgesic via the IO site or elevating the extremity would not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider can be done after stopping the infusion to seek further guidance or intervention.
An 8-year-old child who weighs 60 pounds receives an order for Polycilin (Ampicillin) suspension 25 mg/kg/day divided into a dose every 8 hours. The medication is labeled '125 mg/5 ml'. How many ml should the nurse administer per dose every 8 hours?
- A. 5
- B. 10
- C. 15
- D. 20
Correct Answer: A
Rationale: Calculate the daily dose first: 60 pounds x 25 mg/kg = 1500 mg/day. Divide by 3 doses = 500 mg/dose. Convert to mL: (500 mg / 125 mg) x 5 ml = 20 ml. However, the question asks for the dose per administration every 8 hours, which is 1/3 of the daily dose. So, the correct calculation should be (20 ml / 3) = 6.67 ml, which rounds to 5 ml. Therefore, the correct answer is 5 ml. Choice B (10 ml) is incorrect because it doesn't consider the frequency of dosing. Choice C (15 ml) is incorrect as it overestimates the dose. Choice D (20 ml) is incorrect as it represents the total daily dose, not the dose per administration every 8 hours.
The nurse is making assignments for a new graduate from a practical nursing program who is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign this newly graduate practical nurse? A client
- A. Whose discharge has been delayed because of a postoperative infection
- B. With poorly controlled type 2 diabetes who is on a sliding scale for insulin administration
- C. Newly admitted with a head injury who requires frequent assessments
- D. Who is receiving IV heparin that is regulated based on protocol
Correct Answer: A
Rationale: The correct answer is option A because this client is the most stable and requires less supervision. Assigning a client whose discharge has been delayed due to a postoperative infection to the newly graduate practical nurse would be appropriate during a busy day as they are likely to need routine care and monitoring rather than immediate intensive interventions. Option B involves a client with poorly controlled type 2 diabetes on a sliding scale for insulin administration, which requires close monitoring and prompt intervention, making it a less suitable assignment for a new graduate who may need more guidance. Option C, a newly admitted patient with a head injury requiring frequent assessments, would demand a higher level of vigilance and expertise, which may be challenging for a new graduate nurse to handle without adequate supervision. Option D, a patient receiving IV heparin regulated based on protocol, involves complex medication management that may be too advanced for a new graduate nurse without sufficient oversight.
What is the primary focus of postoperative nursing care for the client with colon trauma?
- A. Monitoring for elevated coagulation studies
- B. Observation for and prevention of fistulas
- C. Monitoring for signs of hyponatremia
- D. Observation for and prevention of infection
Correct Answer: D
Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.