Nokea
A nurse is caring for a client in a provider's office. Which of the following statements should the nurse include when teaching the client about the prescribed medication? Select all that apply.
- A. The medication can cause nausea, so take with a meal
- B. You can experience vivid nightmares."
- C. You may notice your urine becomes lighter in color
- D. Consumption of a high protein meal can reduce the effectiveness of the medication
- E. You may initially notice an increase in involuntary movements
- F. This medication can make you light-headed if you stand up too quickly from a seated or lying position
Correct Answer: A, B, E, F
Rationale: Correct Answer: A, B, E, F
Rationale:
A: Taking the medication with a meal can help reduce nausea, enhancing tolerance.
B: Mentioning vivid nightmares prepares the client for a potential side effect.
E: Increase in involuntary movements is a common side effect of certain medications.
F: Informing about potential dizziness upon standing up quickly promotes safety.
These statements address medication effects and side effects, promoting client understanding and safety.
Incorrect Choices:
C: Urine color change may not be relevant to the medication being discussed.
D: High protein meal interaction is not mentioned for this medication.
Incorrect choices lack relevance or do not address potential medication effects, making them not suitable for client education.
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A nurse is monitoring laboratory values for a client who has chronic heart failure and is receiving digoxin. Which of the following values should the nurse report to the provider?
- A. Sodium 1.38 mEq/dL
- B. Magnesium 1.5 mEq/L
- C. BUN level 10 mg/dL
- D. Potassium 2.9 mEq/L
Correct Answer: D
Rationale: The correct answer is D: Potassium 2.9 mEq/L. Low potassium levels can predispose the client to digoxin toxicity, leading to potentially life-threatening arrhythmias. Hypokalemia increases the risk of digoxin binding to cardiac tissue, enhancing its toxic effects. The nurse should report this value to the provider immediately for prompt intervention to prevent complications.
Incorrect Choices:
A: Sodium 1.38 mEq/dL - Low sodium levels are not directly related to digoxin toxicity.
B: Magnesium 1.5 mEq/L - While magnesium levels are important for cardiac function, they are not as directly linked to digoxin toxicity as potassium.
C: BUN level 10 mg/dL - BUN levels are not specific indicators of digoxin toxicity.
Summary: Potassium levels are crucial to monitor in clients taking digoxin due to the risk of toxicity. Sodium, magnesium, and BUN levels are important but not as
A nurse is caring for a client who is to receive potassium replacement. The provider's prescription reads, 'Potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 min.' Which of the following reasons should the nurse clarify this prescription with the provider?
- A. Potassium chloride should be diluted in dextrose 5% in water.
- B. The potassium infusion rate is too rapid.
- C. Another formulation of potassium should be given IV.
- D. The client should be treated by giving potassium by IV bolus.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Potassium chloride infusion rate should not exceed 10 mEq/hr to prevent hyperkalemia and cardiac arrhythmias.
2. In this case, 30 mEq in 100 mL over 30 min exceeds the safe rate.
3. Clarification is needed to adjust the infusion rate to avoid potential harm.
4. Other choices are incorrect as dextrose dilution, different formulations, and IV bolus are not the primary concerns.
A nurse is assessing a client who reports taking over-the-counter antacids. Which of the following findings should the nurse identify as a manifestation of hypercalcemia?
- A. Constipation
- B. Decreased urine output
- C. Positive Trousseau's sign
- D. Headache
Correct Answer: A
Rationale: The correct answer is A: Constipation. Hypercalcemia can result from excessive intake of antacids containing calcium carbonate. High levels of calcium in the blood can lead to constipation due to its inhibitory effect on smooth muscle contraction in the intestinal tract. Decreased urine output (choice B) is more indicative of dehydration or renal issues. Positive Trousseau's sign (choice C) is associated with hypocalcemia, not hypercalcemia. Headache (choice D) is a nonspecific symptom and not a typical manifestation of hypercalcemia.
A nurse is caring for a client who has a prescription for total parenteral nutrition (TPN). Which of the following routes of administration should the nurse use?
- A. Subcutaneous
- B. Intravenous
- C. Central venous access device
- D. Midline catheter
Correct Answer: C
Rationale: The correct answer is C: Central venous access device. TPN is a highly concentrated solution that provides all the nutrients a person needs intravenously. A central venous access device allows for the infusion of TPN into a large central vein, such as the superior vena cava, ensuring immediate access to the bloodstream for rapid absorption. Using other routes like subcutaneous (A), intravenous (B), or midline catheter (D) may not be suitable due to the high osmolarity of TPN, which can cause irritation and damage to smaller veins. Therefore, a central venous access device is the most appropriate and safe route for administering TPN.
A nurse is caring for a client who has breast cancer and reports pain. 1 hr after administration of prescribed morphine 10 mg IV. Which of the following medications should the nurse expect to administer?
- A. Naloxone IV
- B. Morphine tablet
- C. Lidocaine patch
- D. Fentanyl transmucosal
Correct Answer: D
Rationale: The correct answer is D: Fentanyl transmucosal. Fentanyl is a potent opioid used for severe pain, and transmucosal administration provides rapid relief. Naloxone (A) is an opioid antagonist used to reverse opioid overdose, not for pain management. Morphine tablet (B) is not indicated for immediate relief after IV morphine. Lidocaine patch (C) is used for localized pain, not post-IV opioid pain control. Therefore, fentanyl transmucosal (D) is the most appropriate choice for rapid pain relief in this scenario.