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The client, hospitalized with an exacerbation of SLE, is to receive methylprednisolone 20 mg IV q8h. Which intervention should the nurse anticipate being included in the client's plan of care?
- A. Take orthostatic BPs at least twice daily.
- B. Administer a stool softener twice daily.
- C. Premedicate with diphenhydramine.
- D. Check blood glucose before meals and at bedtime.
Correct Answer: D
Rationale: A: Clients receiving systemic corticosteroids are at risk for hypertension, not orthostatic hypotension. B: Constipation is not an adverse effect of corticosteroid therapy. C: Antihistamine medications are not used before administration of corticosteroids. D: Methylprednisolone (Medrol, Solu-Medrol) is a corticosteroid. Therapy with corticosteroids causes hyperglycemia. The blood glucose level should be monitored.
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The LPN is taking care of a client with a documented allergy to Penicillin. After rounds, the PN notices that the client has an order for Cefazolin. Which of the following actions would be the least appropriate?
- A. The LPN clarifies the severity of the Penicillin allergy.
- B. The LPN discusses the order with the care team prior to administering Cefazolin.
- C. The LPN administers all ordered medications except for the Cefazolin.
- D. The LPN monitors the client after a test dose of Cefazolin is administered.
Correct Answer: C
Rationale: The LPN should clarify the order with the care team prior to determining the medication should not be given. Even though the client may have a potential reaction due to the Penicillin allergy, the therapeutic benefits of the antibiotic may outweigh the allergic reaction.
The nurse is developing a teaching plan for the client prescribed nortriptyline. Which self-care aspects should be included to minimize medication side effects and prevent injury? Select all that apply.
- A. Avoid eating processed meats, cheeses, and wines.
- B. Suck on candy or ice chips to keep your mouth moist.
- C. Run water in the bathroom to stimulate urination if needed.
- D. Increase fluid and fiber in the diet to prevent constipation.
- E. Avoid driving until vision is completely clear to prevent injury.
- F. Increase exposure to sunlight to facilitate vitamin D absorption.
Correct Answer: B,C,D,E
Rationale: Nortriptyline (Pamelor) causes dry mouth, urinary retention, constipation, and blurred vision. Sucking on candy, running water to stimulate urination, increasing fluid and fiber, and avoiding driving until vision is clear are appropriate.
During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis?
- A. Brain
- B. Bone
- C. Liver
- D. Mediastinum
Correct Answer: C
Rationale: Rectal adenocarcinoma commonly metastasizes to the liver via the portal vein and lymphatics, making it the most likely next site.
The client admitted for inpatient treatment of an anxiety disorder has been taking fluoxetine for the past 9 months. The HCP prescribes a new antianxiety medication and discontinues fluoxetine. What is the nurse's most appropriate intervention?
- A. Monitor the client closely for dizziness and lethargy due to discontinuation syndrome.
- B. Teach the client relaxation measures to use while adjusting to the new antianxiety drug.
- C. Call the HCP to question whether fluoxetine should be iżtapered rather than discontinued.
- D. Reassure the client that there is little risk of adverse effects when discontinuing fluoxetine.
Correct Answer: D
Rationale: Because of its long half-life, there is a relatively low risk of adverse effects when discontinuing fluoxetine (Prozac). The client should be reassured and taught about the change of antianxiety medication.
The nurse is developing the teaching plan for the client who is started on amitriptyline. Which information is most appropriate to include?
- A. Discuss a calorie-controlled diet plan suitable to the client's preferences.
- B. Inform about possible sexual dysfunction and be ready to provide support.
- C. Instruct to stop amitriptyline immediately if having a sudden elevation in BP.
- D. Advise to take amitriptyline upon waking up to manage the side effect of insomnia.
Correct Answer: A
Rationale: Weight gain is often a major concern for clients taking TCAs such as amitriptyline (Elavil). A calorie-controlled diet plan will assist in avoiding weight gain.