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A 70-year-old patient has just received a drug that can cause sedation. What would be the priority nursing diagnosis for this patient?
- A. Deficient Knowledge, unfamiliar with drug therapy.
- B. Ineffective health maintenance, need for medication.
- C. Risk for injury, related to adverse effect of the drug.
- D. Noncompliance, cost of the drug.
Correct Answer: C
Rationale: The correct answer is C: Risk for injury, related to adverse effect of the drug. This is the priority nursing diagnosis because the patient, being 70 years old and receiving a sedating drug, is at an increased risk for falls and other injuries due to sedation. It is crucial for the nurse to monitor the patient closely for signs of sedation and take appropriate measures to prevent potential harm.
Choice A (Deficient Knowledge) is not the priority as the immediate concern is the risk of injury. Choice B (Ineffective health maintenance) focuses on the need for medication, not the potential risk of injury. Choice D (Noncompliance) is not relevant in this situation as it pertains to the cost of the drug, not the immediate safety of the patient.
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A patient who has Parkinson's will begin taking carbidopa-levodopa. What information will the nurse include when teaching this patient about this medication?
- A. Discontinue the drug if you experience insomnia.
- B. Rise slowly from your bed or chair to avoid dizziness and falls.
- C. Call your health care provider immediately if your urine turns a dark color.
- D. Take the drug with foods high in protein to improve drug delivery.
Correct Answer: B
Rationale: The correct answer is B: Rise slowly from your bed or chair to avoid dizziness and falls. This is because carbidopa-levodopa can cause orthostatic hypotension, leading to dizziness and potential falls when standing up quickly. Instructing the patient to rise slowly can help prevent this adverse effect.
Choice A is incorrect because insomnia is not a common side effect of carbidopa-levodopa, so there is no need to discontinue the drug solely for this reason.
Choice C is incorrect as dark-colored urine is not a typical side effect of carbidopa-levodopa and does not warrant immediate medical attention.
Choice D is incorrect because taking carbidopa-levodopa with high-protein foods can actually decrease the absorption of the medication, potentially reducing its effectiveness.
Therefore, the most important information for the patient to remember is to rise slowly to prevent dizziness and falls.
What concept is considered when generic drugs are substituted for brand-name drugs?
- A. Half Life.
- B. Critical concentration.
- C. Distribution.
- D. Bioavailability.
Correct Answer: D
Rationale: The correct answer is D: Bioavailability. Bioavailability refers to the extent and rate at which the active ingredient of a drug is absorbed and becomes available at the site of action in the body. When generic drugs are substituted for brand-name drugs, bioavailability is crucial to ensure that the generic drug delivers the same therapeutic effect as the brand-name drug. A higher bioavailability indicates that the generic drug is absorbed efficiently and can produce the desired clinical effect. Half-life (A) is the time required for the concentration of a drug in the body to decrease by half, not directly related to drug substitution. Critical concentration (B) is the minimum concentration of a drug needed to produce a therapeutic effect, not specifically considered in drug substitution. Distribution (C) refers to the process of drug transport within the body, not directly linked to drug substitution.
A 54-year-old man has a myocardial infarction, resulting in left-sided heart failure. The nurse caring for the man is most concerned that he will develop edema in what area of the body.
- A. Peripheral.
- B. Pulmonary.
- C. Liver.
- D. Abdominal.
Correct Answer: B
Rationale: The correct answer is B: Pulmonary. Left-sided heart failure leads to the accumulation of fluid in the lungs, causing pulmonary edema. As the heart fails to pump effectively, blood backs up into the pulmonary circulation, leading to increased pressure in the blood vessels of the lungs. This results in fluid leakage into the alveoli, impairing gas exchange and causing symptoms like shortness of breath and coughing. Peripheral edema (choice A) occurs in right-sided heart failure due to fluid accumulation in the extremities. Liver congestion (choice C) can lead to hepatomegaly but is not the primary concern in this case. Abdominal edema (choice D) may occur in severe cases but is not as immediate a concern as pulmonary edema in left-sided heart failure.
The nurse admits a patient to the unit and learns the patient has recently been diagnosed with chronic renal failure but has not informed the primary care provider of this diagnosis. What is the nurse's first priority?
- A. Maintain the patient's confidentiality.
- B. Administer medications ordered immediately.
- C. Provide teaching about chronic renal failure.
- D. Call the admitting physician immediately.
Correct Answer: D
Rationale: The correct answer is D: Call the admitting physician immediately. The nurse's first priority should be to inform the physician of the patient's recent diagnosis of chronic renal failure to ensure appropriate care and treatment. This action is crucial for the patient's safety and well-being. Maintaining confidentiality (A) is important but not the priority in this situation. Administering medications (B) should only be done after informing the physician about the diagnosis. Providing teaching (C) about the condition can wait until the physician is informed.
The nurse is caring for a patient receiving warfarin and notes bruising and petechiae on the patient's extremities. The nurse will request an order for which?
- A. Vitamin K Level.
- B. PTT and aPTT.
- C. International normalized ratio (INR).
- D. Platelet level.
Correct Answer: C
Rationale: The correct answer is C: International normalized ratio (INR). When a patient on warfarin presents with bruising and petechiae, it suggests potential over-anticoagulation. INR measures the effectiveness of warfarin therapy by assessing clotting time. An elevated INR indicates a higher risk of bleeding due to excessive anticoagulation. Ordering a Vitamin K level (choice A) is not necessary as the patient is already on warfarin. PTT and aPTT (choice B) are not specific to monitoring warfarin therapy. Platelet level (choice D) is not indicated for assessing warfarin effects.