Nokea
A client has been prescribed lisinopril. Which of the following medication interactions should the nurse instruct this client about?
- A. Potassium supplements
- B. Ciprofloxacin
- C. Escitalopram
- D. Magnesium supplements
Correct Answer: A
Rationale: The correct answer is A: Potassium supplements. Clients taking lisinopril should avoid potassium supplements and potassium-sparing diuretics due to the risk of hyperkalemia. This interaction can lead to dangerously high levels of potassium in the blood, which can be harmful. Choice B, Ciprofloxacin, is not typically associated with a significant interaction with lisinopril. Choice C, Escitalopram, is an antidepressant and does not have a known significant interaction with lisinopril regarding potassium levels. Choice D, Magnesium supplements, are generally safe to take with lisinopril and do not pose a significant risk of hyperkalemia.
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A nurse is caring for a client receiving IV vancomycin. The nurse notes flushing of the client's neck and chest. Which of the following actions should the nurse take?
- A. Stop the infusion
- B. Document the findings as a harmless reaction
- C. Slow the infusion rate
- D. Administer diphenhydramine
Correct Answer: C
Rationale: The correct action for the nurse to take when a client receiving IV vancomycin shows flushing of the neck and chest is to slow the infusion rate. Flushing is a common sign of Red Man Syndrome, which is associated with rapid infusions of vancomycin. Slowing down the infusion rate can help prevent further flushing and the development of Red Man Syndrome. Stopping the infusion (Choice A) may be too drastic if the symptoms are mild and can be managed by slowing the rate. Documenting the findings as a harmless reaction (Choice B) is incorrect because flushing should be addressed promptly to prevent complications. Administering diphenhydramine (Choice D) is not the initial or best intervention for flushing associated with vancomycin; slowing the infusion rate is the priority.
A nurse is providing client education regarding lithium therapy. Which of the following instructions should the nurse include?
- A. Take with food to decrease nausea
- B. Avoid excessive intake of caffeinated beverages
- C. Monitor for signs of dehydration
- D. Restrict salt intake to prevent water retention
Correct Answer: B
Rationale: The correct answer is B. The nurse should instruct the client to avoid excessive intake of caffeinated beverages as they can interfere with lithium levels. Option A is incorrect as lithium is usually recommended to be taken on an empty stomach. Option C is not directly related to lithium therapy. Option D is not a typical instruction for lithium therapy.
A nurse is administering metformin to a client with type 2 diabetes. Which of the following adverse effects should the nurse monitor for in this client?
- A. Diarrhea
- B. Hyperglycemia
- C. Hypoglycemia
- D. Lactic acidosis
Correct Answer: D
Rationale: The correct answer is D, Lactic acidosis. Lactic acidosis is a rare but serious adverse effect of metformin use. Metformin is not known to cause hyperglycemia or hypoglycemia. Diarrhea is a common gastrointestinal side effect of metformin but is not as serious as lactic acidosis, which requires immediate medical attention.
A client is receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?
- A. Slow the infusion and continue to monitor the site
- B. Stop the infusion
- C. Apply a warm compress to the site
- D. Apply a cold compress to the site
Correct Answer: B
Rationale: When an IV site appears infiltrated, it indicates that the medication is leaking into the surrounding tissues. In such a situation, the infusion should be stopped immediately to prevent further tissue damage. Choice A is incorrect because slowing the infusion would still allow the medication to leak into the tissues. Choices C and D are also incorrect as applying compresses can exacerbate the tissue damage caused by infiltration.
A nurse is preparing to administer nitroglycerin ointment to a client. Which of the following actions should the nurse take?
- A. Apply the ointment to the client's hairless chest
- B. Rub the ointment gently into the skin
- C. Cover the applied ointment with a transparent dressing
- D. Massage the ointment into the skin
Correct Answer: A
Rationale: The correct action is to apply the nitroglycerin ointment to a hairless area of the client's chest, back, or upper arms. This allows for better absorption of the medication. Choice B is incorrect because rubbing the ointment gently into the skin may be appropriate, but the primary action is to ensure application on a hairless area. Choice C is incorrect as covering the ointment with a transparent dressing is not a standard practice for nitroglycerin ointment administration. Choice D is incorrect because massaging the ointment into the skin is not recommended, as it can alter absorption rates.