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A client in the surgical recovery area asks the nurse to bring the largest possible dose of pain medication available. Which action should the nurse implement first?
- A. Determine when the last dose was administered.
- B. Review the history for past use of recreational drugs.
- C. Ask the client to rate the current level of pain using a pain scale.
- D. Encourage the client to use diversional thoughts to manage pain.
Correct Answer: C
Rationale: Assessing the client’s pain level using a pain scale (C) is the first step to quantify pain and guide appropriate dosing. Determining the last dose (A) and reviewing drug history (B) are secondary. Diversional thoughts (D) are a non-pharmacological adjunct, not the priority.
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After taking orlistat for one week, a female patient tells the home health nurse that she is experiencing increasingly frequent oily stools and gas. What action should the nurse take?
- A. Ask the patient to describe her dietary intake history for the last several days.
- B. Advise the patient to stop taking the drug and contact her healthcare provider.
- C. Instruct the patient to increase her intake of saturated fats over the next week.
- D. Obtain a stool specimen to evaluate for occult blood and fat content.
Correct Answer: A
Rationale: Orlistat inhibits fat absorption, causing oily stools and gas if dietary fat is high. Assessing dietary intake (A) identifies the cause. Stopping the drug (B) is premature. Increasing fats (C) worsens symptoms. Stool testing (D) is unnecessary for known side effects.
A patient is currently on an oral contraceptive and has been prescribed erythromycin. What advice should the nurse provide to the patient?
- A. Utilize an additional form of contraception.
- B. Immediately discontinue the oral contraceptive.
- C. Ensure a 12-hour gap between taking the medications.
- D. Avoid prolonged exposure to direct sunlight.
Correct Answer: A
Rationale: Erythromycin may reduce oral contraceptive efficacy by inducing hepatic metabolism. Using an additional contraceptive method (A) prevents unintended pregnancy. Discontinuing the contraceptive (B) is unnecessary. Timing gaps (C) don’t mitigate the interaction. Sunlight avoidance (D) relates to other antibiotics like tetracycline.
A client with atrial fibrillation has been prescribed dabigatran. What instruction should the nurse include in this client’s teaching plan?
- A. Eliminate spinach and other green vegetables from the diet.
- B. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs).
- C. Continue to obtain scheduled laboratory bleeding tests.
- D. Keep an antidote available in case of hemorrhage.
Correct Answer: B
Rationale: Dabigatran increases bleeding risk; avoiding NSAIDs (B) reduces this risk. Spinach (A) affects warfarin, not dabigatran. Routine bleeding tests (C) aren’t required for dabigatran. Antidotes (D) like idarucizumab are hospital-administered, not kept at home.
After administering five doses of filgrastim, the nurse observes that the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3. What action should the nurse take?
- A. Inform the patient that the medication has been effective.
- B. Review the patient’s culture and sensitivity reports.
- C. Implement neutropenic precautions.
- D. Assess the patient’s vital signs.
Correct Answer: A
Rationale: Filgrastim stimulates white blood cell production. An increase from 2,500/mm^3 to 5,000/mm^3 (A) indicates effectiveness, and the patient should be informed. Culture reports (B) are unrelated to filgrastim’s action. Neutropenic precautions (C) are unnecessary with improved counts. Vital signs (D) don’t directly assess filgrastim’s efficacy.
A client reports confusion and blurred vision after receiving a dose of glipizide. What should the nurse do?
- A. Administer glucagon intramuscularly.
- B. Measure the client’s vital signs.
- C. Obtain a fingerstick blood glucose.
- D. Perform a neurological exam.
Correct Answer: C
Rationale: Glipizide, a sulfonylurea, can cause hypoglycemia, presenting as confusion and blurred vision. Checking blood glucose (C) confirms the cause. Glucagon (A) treats severe hypoglycemia, not confirmed yet. Vital signs (B) and neurological exams (D) are secondary.