Nokea
The nurse is caring for an elderly client who is eight (8) hours postoperative hip replacement and is reporting incisional pain. Which intervention is priority for this client?
- A. Assist the client to sit in the bedside chair.
- B. Initiate pain medication at the lowest dose.
- C. Assess the client's pupil size and accommodation.
- D. Monitor the client's urinary output hourly.
Correct Answer: B
Rationale: Pain management is the priority post-op to promote recovery and comfort; lowest dose minimizes side effects in the elderly. Sitting, pupil assessment, or urine output are secondary.
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The client with coronary artery disease is prescribed atorvastatin (Lipitor) to help decrease the client's cholesterol level. Which intervention should the nurse discuss with the client concerning this medication?
- A. The client should eat a low-cholesterol, low-fat diet.
- B. The client should take this medication with each meal.
- C. The client should take this medication in the evening.
- D. The client should monitor daily cholesterol levels.
Correct Answer: C
Rationale: Atorvastatin is most effective at night when cholesterol synthesis peaks, per pharmacodynamics. Diet is supportive, meals are irrelevant, and daily monitoring is impractical.
For which client should the nurse question administering the muscarinic cholinergic agonist oxybutynin (Ditropan)?
- A. The client diagnosed with overactive bladder.
- B. The client diagnosed with type 2 diabetes.
- C. The client diagnosed with glaucoma.
- D. The client diagnosed with peripheral vascular disease.
Correct Answer: C
Rationale: Oxybutynin’s anticholinergic effects can increase intraocular pressure, contraindicating it in glaucoma. It’s appropriate for overactive bladder; diabetes or PVD are not contraindications.
The client asks the clinic nurse if he should take 2,000 mg of vitamin C a day to prevent getting a cold. On which scientific rationale should the nurse base the response?
- A. Vitamin C in this dosage will help cure the common cold.
- B. This vitamin must be taken with echinacea to be effective.
- C. This dose of vitamin C is not high enough to help prevent colds.
- D. Megadoses of vitamin C may cause crystals to form in the urine.
Correct Answer: D
Rationale: Megadoses of vitamin C (>2,000 mg/day) can lead to oxalate crystal formation in urine, increasing kidney stone risk. Evidence for cold prevention is weak, and echinacea or higher doses are not supported.
The client diagnosed with status asthmaticus is prescribed intravenous aminophylline, a bronchodilator. Which assessment data would warrant immediate intervention?
- A. The theophylline level is 12 mcg/mL.
- B. The client has expiratory wheezing.
- C. The client complains of muscle twitching.
- D. The client is refusing to eat the meal.
Correct Answer: C
Rationale: Muscle twitching indicates theophylline toxicity, requiring immediate intervention. Normal levels (10–20 mcg/mL), wheezing, or meal refusal are expected or less urgent.
The nurse has received the morning report and has the following medications due or being requested. In which order should the nurse administer the medications? List in order of priority.
- A. Administer furosemide (Lasix), a loop diuretic, IVP daily to a client diagnosed with heart failure who is dyspneic on exertion.
- B. Administer morphine, a narcotic analgesic, IVP prn to a client diagnosed with lower back pain who is complaining of pain at a '10' on a 1-to-10 scale.
- C. Administer neostigmine (Prostigmin), a cholinesterase inhibitor, PO to a client diagnosed with myasthenia gravis.
- D. Administer lidocaine, an antidysrhythmic, IVP prn to a client in normal sinus rhythm with multifocal premature ventricular contractions.
- E. Administer vancomycin, an aminoglycoside antibiotic, to a client diagnosed with a Staphylococcus infection who has a trough level of 14 mg/dL.
Correct Answer: B,D,A,C,E
Rationale: 1) Morphine for severe pain (acute, 10/10); 2) Lidocaine for PVCs (cardiac risk); 3) Furosemide for dyspnea (respiratory distress); 4) Neostigmine for myasthenia (muscle strength); 5) Vancomycin (infection, stable trough).