Nokea
A 60-year-old client has been hospitalized for deep vein thrombosis. The client is to be discharged on warfarin (Coumadin) 5 mg PO daily. Which statement that the client makes indicates the best understanding of the medication routine?
- A. I will take aspirin for my arthritis.
- B. I love to eat spinach salads.
- C. I will get a blood test next week.
- D. I made an appointment to have my teeth pulled.
Correct Answer: C
Rationale: Warfarin requires regular INR monitoring via blood tests to ensure therapeutic anticoagulation levels.
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The client in end-stage renal disease is a Jehovah's Witness. The HCP orders erythropoietin (Epogen), a biologic response modifier, subcutaneously for anemia. Which action should the nurse take?
- A. Question this order because of the client's religion.
- B. Encourage the client to talk to his or her minister.
- C. Administer the medication subcutaneously as ordered.
- D. Obtain the informed consent prior to administering.
Correct Answer: C
Rationale: Epogen is synthetic, not blood-derived, so it’s acceptable for Jehovah’s Witnesses. Administer as ordered; questioning, minister consultation, or consent are unnecessary.
The nurse is preparing to administer phenytoin (Dilantin), 100 mg intravenous push, to the client with a head injury who has an IV of D5W at 50 mL/hr. Which intervention should the nurse implement?
- A. Flush the IV tubing before and after with normal saline.
- B. Administer the medication if the Dilantin level is 22 mcg/mL.
- C. Push the Dilantin intravenously slowly over five (5) minutes.
- D. Expect the intravenous tubing to turn cloudy when infusing medication.
Correct Answer: A
Rationale: Phenytoin is incompatible with D5W; saline flush prevents precipitation. Level of 22 mcg/mL is toxic, slow push is correct but not primary, and cloudiness is avoidable.
Penicillin V potassium (Pen-Vee-K) 500 mg PO qid is ordered for an adult client. He reports that he took penicillin for the first time two months ago. What should the nurse do?
- A. Be sure that skin testing for a penicillin allergy has been done
- B. Observe for signs of an allergic response
- C. Withhold the penicillin
- D. Notify the physician
Correct Answer: B
Rationale: The client does not have a history of allergic response to penicillin, so there is no need to skin test or withhold the medication. However, allergic responses often occur after the first administration.
A client is receiving digitalis. The nurse should instruct the client to report which of the following side effects?
- A. Nausea, vomiting, fatigue
- B. Rash, dyspnea, edema
- C. Polyuria, thirst, dry skin
Correct Answer: A
Rationale: Nausea, vomiting, fatigue. Side effects of digitalis toxicity include fatigue, nausea, vomiting, anorexia, and bradycardia. Digitalis inhibits the sodium potassium ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac output.
The client diagnosed with chronic obstructive pulmonary disease is being discharged and is prescribed the steroid prednisone. Which scientific rationale supports why the nurse instructs the client to taper off the medication?
- A. The pituitary gland must adjust to the decreasing dose.
- B. The beta cells of the pancreas have to start secreting insulin.
- C. This will allow the adrenal gland time to start functioning.
- D. The thyroid gland will have to start producing cortisol.
Correct Answer: C
Rationale: Prednisone suppresses adrenal cortisol production; tapering allows adrenal glands to resume function, preventing adrenal crisis.