Nokea
A client has been receiving dexamethasone (Decadron) for control of cerebral edema. Which of the following assessments would indicate that the treatment is effective?
- A. A positive Babinski's reflex
- B. Increased response to motor stimuli
- C. A widening pulse pressure
- D. Temperature of 37 degrees Celsius
Correct Answer: B
Rationale: Decadron is a corticosteroid that acts on the cell membrane to decrease inflammatory responses as well as stabilize the blood-brain barrier. Once Decadron reaches a therapeutic level, there should be a decrease in symptomatology with improvement in motor skills.
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The client is receiving the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec). When would the nurse question administering this medication?
- A. The client is not receiving potassium supplements.
- B. The client complains of a persistent irritating cough.
- C. The blood pressure for two (2) consecutive readings is 110/70.
- D. The client's urinary output is 400 mL for the last eight (8) hours.
Correct Answer: B
Rationale: A persistent cough is a common ACE inhibitor side effect, warranting discontinuation or HCP evaluation. Potassium, BP, or urine output are less critical.
The nurse practicing in a long term care facility recognizes that elderly clients are at greater risk for drug toxicity than younger adults because of which of the following physiological changes of advancing age?
- A. Drugs are absorbed more readily from the GI tract
- B. Elders have less body water and more fat
- C. The elderly have more rapid hepatic metabolism
- D. Older people are often malnourished and anemic
Correct Answer: B
Rationale: Elders have less body water and more fat. Because elderly persons have decreased lean body tissue/water in which to distribute medications, more drug remains in the circulatory system with potential for drug toxicity. Increased body fat results in greater amounts of fat-soluble drugs being absorbed, leaving less in circulation, thus increasing the duration of action of the drug.
The employee health nurse is discussing hepatitis B vaccines with new employees. Which statement best describes the proper administration of the hepatitis B vaccine?
- A. The vaccine must be administered once a year.
- B. Two (2) mL of vaccine should be given in each hip.
- C. The vaccine is given in three (3) doses over a six (6)-month time period.
- D. The vaccine is administered intradermally into the deltoid muscle.
Correct Answer: C
Rationale: Hepatitis B vaccine is given in three IM doses (0, 1, 6 months), per CDC guidelines. Annual dosing, split doses, or intradermal routes are incorrect.
The elderly male client is admitted for acute severe diverticulitis. He has been taking Xanax, a benzodiazepine, for nervousness three (3) to four (4) times a day prn for six (6) years. Which intervention should the nurse implement first?
- A. Prepare to administer an intravenous antianxiety medication.
- B. Notify the HCP to obtain an order for the client's Xanax prn.
- C. Explain Xanax causes addiction and he should quit taking it.
- D. Assess for signs/symptoms of medication withdrawal.
Correct Answer: D
Rationale: Long-term Xanax use risks dependence; assessing withdrawal (e.g., agitation, seizures) is the priority during acute illness to guide safe management.
An adult client has pulmonary tuberculosis. He is receiving isoniazid (INH) 300 mg PO, ethambutol 1 g PO daily, and streptomycin 1 g IM three times a week. When he comes in for a checkup, he tells the nurse that he hates getting shots and his ears ring most of the time. What is the best interpretation for the nurse to make regarding the client's complaints?
- A. He may be receiving too much ethambutol.
- B. He should be evaluated for adverse reaction to streptomycin.
- C. Tuberculosis may have spread to the brain.
- D. He is experiencing a reaction commonly seen when INH and streptomycin are given at the same time.
Correct Answer: B
Rationale: Streptomycin is ototoxic, and ringing in the ears (tinnitus) is a sign of potential eighth cranial nerve damage, requiring evaluation.