Nokea
A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device. Which of the following actions by the nurse requires intervention by the charge nurse?
- A. The nurse monitors the client for oversedation
- B. The nurse reassures the client that the PCA device will not cause an overdose
- C. The nurse asks the client to demonstrate dose delivery.
- D. The nurse administers a PCA dose for the client.
Correct Answer: D
Rationale: Correct Answer: D. The nurse administering a PCA dose for the client requires intervention. This is because only the client should be allowed to self-administer medication via a PCA device to ensure safety and prevent medication errors. Allowing the nurse to administer the dose goes against the principles of PCA therapy, which empowers the client to manage their pain relief within safe limits.
Choice A: Monitoring the client for oversedation is a standard nursing practice and does not require intervention.
Choice B: Reassuring the client about the PCA device is important for patient education but does not require immediate intervention.
Choice C: Asking the client to demonstrate dose delivery is a proactive approach to ensure the client understands how to use the device correctly and does not require intervention unless the client is unable to demonstrate understanding.
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A nurse is planning care for a client who has angina and a new prescription for nitroglycerin ointment. Which of the following actions should the nurse plan to take?
- A. Cover the administration area with plastic wrap.
- B. Massage the ointment into the skin.
- C. Spread the ointment in a 10 cm2 (4in2) area.
- D. Apply the ointment in a thick layer.
Correct Answer: A
Rationale: The correct answer is A. The nurse should cover the administration area with plastic wrap when applying nitroglycerin ointment to prevent accidental exposure to others and to ensure proper absorption of the medication. This step helps to enhance the drug's efficacy by promoting direct contact with the skin and preventing it from being rubbed off onto clothing or other surfaces. Massaging the ointment into the skin (B) may alter the absorption rate and distribution of the medication. Spreading the ointment in a 10 cm2 area (C) may lead to inaccurate dosing. Applying the ointment in a thick layer (D) may result in overdose or underdose due to inconsistent dosing.
A nurse is monitoring a client's response to receiving glipizide instead of guaifenesin. Which of the following actions should the nurse take?
- A. Lower the head of the client's bed.
- B. Check the client for urinary retention
- C. Offer the client a carbohydrate snack.
- D. Test the client's deep-tendon reflexes.
Correct Answer: C
Rationale: The correct answer is C: Offer the client a carbohydrate snack. Glipizide is an oral antidiabetic medication that can lower blood sugar levels by stimulating the release of insulin from the pancreas. If the client receives glipizide instead of guaifenesin (an expectorant), there is a risk of hypoglycemia due to the medication's blood sugar-lowering effects. Offering a carbohydrate snack can help prevent or treat hypoglycemia by quickly raising blood sugar levels. Lowering the head of the bed (A), checking for urinary retention (B), and testing deep-tendon reflexes (D) are not directly related to the client's response to glipizide.
A nurse is collecting data from a client who reports nausea and has vomited clear emesis. Which of the following medications should the nurse administer?
- A. Meperidine
- B. Diazepam
- C. Naloxone
- D. Promethazine
Correct Answer: D
Rationale: The correct answer is D: Promethazine. Promethazine is an antiemetic medication commonly used to treat nausea and vomiting. It works by blocking dopamine receptors in the brain, reducing the feeling of nausea. Meperidine (A) is a pain medication and not indicated for nausea. Diazepam (B) is a benzodiazepine used for anxiety and seizures, not for nausea. Naloxone (C) is an opioid antagonist used for opioid overdose, not for nausea.
A nurse is reviewing the medication administration record of a client who has a wound infection. The client has prescriptions for cefotetan and an NSAID. The nurse should monitor for which of the following medication interactions?
- A. Bleeding
- B. Dysrhythmias
- C. Dizziness
- D. Jaundice
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Cefotetan is a cephalosporin antibiotic that can increase the risk of bleeding when taken with NSAIDs due to their additive effects on platelet function. The combination can lead to gastrointestinal bleeding or bruising. Dysrhythmias (choice B) are not typically associated with this drug combination. Dizziness (choice C) and jaundice (choice D) are not common interactions with cefotetan and NSAIDs.
A nurse is caring for a client who is experiencing acute alcohol withdrawal. The nurse should anticipate administering which of the following medications to the client to facilitate the withdrawal process?
- A. Varenicline
- B. Diazepam
- C. Clonidine
- D. Methadone
Correct Answer: B
Rationale: The correct answer is B: Diazepam. Diazepam is a benzodiazepine that is commonly used to manage acute alcohol withdrawal symptoms by reducing anxiety, agitation, and preventing seizures. It acts on the GABA receptors to produce a calming effect. Varenicline (A) is used for smoking cessation, not alcohol withdrawal. Clonidine (C) is mainly used for hypertension and opioid withdrawal, not alcohol withdrawal. Methadone (D) is used for opioid dependence, not alcohol withdrawal.