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The nurse is caring for a client who complains of a headache with a pain level of 5 on a scale of 1 to 10. Which PRN pain medication order is most appropriate for the nurse to administer?
- A. morphine 2 mg IV q6h PRN
- B. aspirin 325 mg PO q6h PRN
- C. acetaminophen 650 mg PO q6h PRN
- D. nitroglycerin 0.4 mg sublingually every 5 minutes, up to 3 doses over 15 minutes
Correct Answer: C
Rationale: Acetaminophen 650 mg PO (C) is appropriate for a moderate headache (pain level 5). Morphine (A) is too strong, aspirin (B) is less ideal due to bleeding risk, and nitroglycerin (D) is for angina.
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The ED nurse has admitted a client with suspected overdose of tricyclic antidepressants. Which signs and symptoms does the nurse expect to find in this client? Select all that apply.
- A. confusion
- B. dry mouth
- C. bradycardia
- D. dysrhythmias
- E. constricted pupils
- F. flushing of the skin
Correct Answer: A,B,D
Rationale: Tricyclic antidepressant overdose causes anticholinergic effects (confusion, dry mouth) and cardiotoxicity (dysrhythmias). Tachycardia, not bradycardia, dilated pupils, and no flushing are typical.
The ED nurse admits a client with second-degree burns to the arms and third-degree burns to the legs. Based on the Parkland formula, which IV fluid would the nurse anticipate for this client during the first 24 hours?
- A. D5W
- B. colloid solutions
- C. crystalloid solutions
- D. 5% albumin in isotonic saline
Correct Answer: C
Rationale: The Parkland formula uses crystalloid solutions (e.g., lactated Ringer's) for burn resuscitation in the first 24 hours to restore fluid volume. Colloids and albumin are used later, and D5W is not appropriate.
The nurse is caring for a client with breast cancer who has an order for doxorubicin IV. The nurse anticipates which common side effect of this medication?
- A. permanent hair loss
- B. halos around objects and blurred vision
- C. red urine for 1-2 days after administration
- D. facial flushing and red streaking along the vein
Correct Answer: C
Rationale: Doxorubicin commonly causes red urine for 1-2 days (C) due to its red color. Hair loss (A) is temporary, visual changes (B) are not typical, and flushing/streaking (D) suggest extravasation.
The nurse is caring for a client who presents with increased ammonia levels, elevated BUN, and altered mental status. Which medication would the nurse anticipate the health care provider ordering for this client?
- A. lactulose
- B. sucralfate
- C. lamotrigine
- D. gabapentin
Correct Answer: A
Rationale: Lactulose reduces ammonia levels in hepatic encephalopathy, which presents with elevated ammonia and altered mental status.