Nokea
A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift and the client received atenolol instead of allopurinol. Which of the following actions should the nurse take first?
- A. Obtain the client's blood pressure
- B. Contact the client's provider
- C. Inform the charge nurse
- D. Complete an incident report
Correct Answer: A
Rationale: The correct answer is A: Obtain the client's blood pressure. The nurse's first priority is to assess the client's current condition and potential adverse effects of atenolol. Atenolol is a beta-blocker that can lower blood pressure and heart rate. Obtaining the client's blood pressure will help determine if any immediate interventions are needed. Contacting the provider (B) can be done after assessing the client's condition. Informing the charge nurse (C) is important but not the first priority. Completing an incident report (D) is necessary but should follow immediate client assessment. Other choices are not relevant to the immediate safety and well-being of the client.
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For which of the following adverse effects should the nurse instruct the client taking acetazolamide for chronic open-angle glaucoma to monitor and report?
- A. Tingling of fingers
- B. Constipation
- C. Weight gain
- D. Oliguria
Correct Answer: A
Rationale: The correct answer is A: Tingling of fingers. Acetazolamide is a diuretic commonly used to treat glaucoma. Tingling of fingers is associated with electrolyte imbalances caused by the drug's diuretic effect. This symptom may indicate hypokalemia, a potential side effect of acetazolamide. Monitoring and reporting this symptom promptly can prevent serious complications.
Other choices are incorrect because:
B: Constipation is not a common side effect of acetazolamide.
C: Weight gain is unlikely as acetazolamide is a diuretic causing fluid loss.
D: Oliguria, decreased urine output, is not a usual side effect of acetazolamide.
Which of the following information should the nurse include in the teaching for a school-age child with a new prescription for a fluticasone metered-dose inhaler? (Select all that apply)
- A. Soak the inhaler in water after use
- B. Have your child take one inhalation as needed for shortness of breath
- C. Shake the device prior to administration
- D. A spacer will make it easier to use the device
- E. Rinse your child's mouth following administration
Correct Answer: E
Rationale: The correct answer is E: Rinse your child's mouth following administration. Fluticasone is a corticosteroid inhaler that can cause oral thrush as a side effect. Rinsing the mouth after each use helps prevent this side effect. Choice A is incorrect because soaking the inhaler in water can damage the device. Choice B is incorrect because fluticasone is a maintenance medication, not a rescue inhaler for shortness of breath. Choice C is incorrect because shaking the device is not necessary for a metered-dose inhaler. Choice D is incorrect because while a spacer can help improve inhaler technique, it is not essential for using a metered-dose inhaler.
Which of the following findings is the best indication that morphine has been effective?
- A. The client's vital signs are within normal limits
- B. The client has not requested additional medication
- C. The client is sitting comfortably with eyes closed
- D. The client rates pain as 3 on a scale from 0 to 10
Correct Answer: D
Rationale: The correct answer is D because the client rating pain as 3 on a scale from 0 to 10 indicates that the morphine has effectively reduced their pain. This is a direct measure of the drug's efficacy. Choice A is not a specific indicator of pain relief. Choice B could mean the client is tolerating the pain, not necessarily that the medication is effective. Choice C is subjective and doesn't provide concrete evidence of pain relief.
A nurse administers a dose of metformin to a client instead of the prescribed dose of metoclopramidWhich of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Notify the provider.
- C. Check the client's blood glucose.
- D. Fill out an incident report.
Correct Answer: C
Rationale: The correct answer is C: Check the client's blood glucose. This is the first action the nurse should take because metformin is used to treat diabetes and can lower blood sugar levels. Checking the client's blood glucose will help assess if the client is experiencing hypoglycemia due to the medication error. Reporting the incident to the charge nurse (A) and filling out an incident report (D) are important steps, but assessing the client's immediate condition takes priority. Notifying the provider (B) can be done after ensuring the client's safety. The other options are not relevant to addressing the immediate concern of potential hypoglycemia.
Which of the following information should the nurse manager include in the in-service about pain management with opioids for clients who have cancer?
- A. IM administration is recommended if PO opioids are ineffective
- B. Respiratory depression decreases as opioid tolerance develops
- C. Meperidine is the opioid of choice for treating chronic pain
- D. Withhold PRN pain medication for the client who is receiving opioids every 6 hr
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Respiratory depression is a potential side effect of opioids. Tolerance to this effect develops with prolonged opioid use, reducing the risk over time. This information is crucial for nurses managing cancer pain with opioids to ensure patient safety.
Incorrect Choices:
A: IM administration is not necessarily recommended if PO opioids are ineffective as this can lead to delayed pain relief and potential complications.
C: Meperidine is not the opioid of choice for treating chronic pain due to its toxic metabolite accumulation and increased risk of side effects.
D: Withholding PRN pain medication for clients on scheduled opioids can result in inadequate pain control and compromised quality of life.