Nokea
The elderly client is admitted to the emergency department from a long-term care facility. The client has multiple ecchymotic areas on the body. The client is receiving digoxin, a cardiac glycoside; Lasix, a loop diuretic; Coumadin, an anticoagulant; and Xanax, an antianxiety medication. Which order should the nurse request from the health-care provider?
- A. A STAT serum potassium level.
- B. An order to admit to the hospital for observation.
- C. An order to administer Valium intravenous push.
- D. A STAT international normalized ratio (INR).
Correct Answer: D
Rationale: Ecchymosis with Coumadin suggests bleeding risk; STAT INR assesses anticoagulation status, guiding reversal if needed. Potassium, admission, or Valium are less urgent.
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While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?
- A. As you urinate more, you will need less medication to control fluid.'
- B. You will have to take this medication for about a year.'
- C. The medication must be continued so the fluid problem is controlled.'
- D. Please talk to your health care provider about medications and treatments.'
Correct Answer: C
Rationale: The medication must be continued so the fluid problem is controlled.' This is the most therapeutic response and gives the client accurate information.
A young woman delivered a 7-lb, 8-oz baby boy spontaneously. Ergotrate 0.4 mg q6h for five days is ordered. A half-hour after the nurse administers the first dose, she complains of abdominal cramping. The nurse's best response is based on which understanding?
- A. Cramping indicates a serious adverse reaction.
- B. Cramping can be reduced by abdominal breathing.
- C. The medication is having the desired effect.
- D. The dosage needs to be reduced.
Correct Answer: C
Rationale: Ergotrate causes uterine contractions, leading to cramping, which is the intended effect to prevent postpartum hemorrhage.
The nurse is assessing the elderly client first thing in the morning. The client is confused and sleepy. Which intervention should the nurse implement first?
- A. Determine if the client received a sedative last night.
- B. Allow the client to continue to sleep and do not disturb.
- C. Encourage the client to ambulate in the room with assistance.
- D. Notify the health-care provider about the client's status.
Correct Answer: A
Rationale: Sedatives are a common cause of morning confusion in the elderly; determining recent administration guides next steps.
The nurse is applying silver sulfadiazine (Silvadene) to a child with severe burns to arms and legs. Which side effect should the nurse be monitoring for?
- A. Skin discoloration
- B. Hardened eschar
- C. Increased neutrophils
- D. Urine sulfa crystals
Correct Answer: D
Rationale: Urine sulfa crystals. When applied to extensive areas, silver sulfadiazine may cause a transient neutropenia, as well as renal function changes with sulfa crystals production and kernicterus.
The nurse is providing education for a client with newly diagnosed tuberculosis. Which statement should be included in the information that is given to the client?
- A. Isolate yourself from others until you are finished taking your medication.'
- B. Follow up with your primary care provider in 3 months.'
- C. Continue to take your medications even when you are feeling fine.'
- D. Continue to get yearly tuberculin skin tests.'
Correct Answer: C
Rationale: The most important piece of information the tuberculosis client needs is to understand the importance of medication compliance, even if no longer experiencing symptoms. Clients are most infectious early in the course of therapy. The numbers of acid-fast bacilli are greatly reduced as early as 2 weeks after therapy begins.