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A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective?
- A. The client's extremities are paralyzed.
- B. The peripheral nerve stimulator causes twitching.
- C. The client clenches fist upon command.
- D. The client's Glasgow Coma Scale score is 14.
Correct Answer: A
Rationale: The correct answer is A because the neuromuscular blocker tubocurarine chloride causes muscle paralysis, leading to the extremities being paralyzed. This indicates that the medication is effectively blocking neuromuscular transmission.
B: Twitching with peripheral nerve stimulation indicates incomplete blockade.
C: Clenching fist upon command indicates preserved muscle strength.
D: Glasgow Coma Scale measures level of consciousness, not neuromuscular blockade.
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A patient with chronic obstructive pulmonary disease (COPD) is prescribed tiotropium. What is the primary purpose of this medication?
- A. Reduce mucus production
- B. Relieve bronchospasm
- C. Suppress cough
- D. Thin respiratory secretions
Correct Answer: B
Rationale: The correct answer is B: Relieve bronchospasm. Tiotropium is an anticholinergic medication that acts by relaxing the muscles around the airways, thereby helping to relieve bronchospasm in patients with COPD. This results in improved airflow and reduced shortness of breath.
A: Reduce mucus production - This is incorrect as tiotropium does not directly affect mucus production but rather focuses on bronchospasm relief.
C: Suppress cough - Tiotropium may help with cough associated with COPD by improving airflow, but its primary purpose is not to suppress cough.
D: Thin respiratory secretions - Tiotropium does not have a direct effect on thinning respiratory secretions; its main action is bronchodilation to relieve bronchospasm in COPD.
An outcome for treatment of peripheral vascular disease is, 'The client will have decreased venous congestion.' What client behavior would indicate to the nurse that this outcome has been met?
- A. Avoids prolonged sitting or standing.
- B. Avoids trauma and irritation to skin.
- C. Wears protective shoes.
- D. Quits smoking.
Correct Answer: A
Rationale: The correct answer is A because avoiding prolonged sitting or standing helps improve venous return by preventing blood from pooling in the legs, reducing venous congestion. This behavior promotes circulation and decreases the risk of complications. Choices B, C, and D do not directly address venous congestion or circulation improvement, making them incorrect options. Avoiding trauma and irritation to the skin (B) is important for skin integrity but not specifically for venous congestion. Wearing protective shoes (C) is related to preventing foot injuries but does not directly impact venous congestion. Quitting smoking (D) is beneficial for overall health but does not directly target venous congestion.
A client with heart failure is prescribed digoxin (Lanoxin). Which instruction should the nurse include in the client's teaching plan?
- A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute.
- B. Increase your intake of foods high in potassium.
- C. Take the medication with a high-fiber meal to enhance absorption.
- D. Skip a dose if you feel dizzy or lightheaded.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Digoxin is a medication that can cause bradycardia as a side effect.
2. Instructing the client to take their pulse before each dose is crucial to monitor for bradycardia.
3. Holding the medication if the pulse is below 60 beats per minute helps prevent potential adverse effects.
4. This instruction ensures the client's safety and adherence to the prescribed regimen.
Summary:
- Choice B is incorrect because increasing potassium intake can lead to hyperkalemia when taking digoxin.
- Choice C is incorrect as taking digoxin with a high-fiber meal may affect absorption negatively.
- Choice D is incorrect because skipping a dose based on dizziness or lightheadedness may lead to suboptimal treatment outcomes.
A patient with diabetes insipidus is prescribed desmopressin. What is the primary purpose of this medication?
- A. Increase urine output
- B. Reduce blood sugar levels
- C. Decrease urine output
- D. Lower blood pressure
Correct Answer: C
Rationale: Desmopressin is a synthetic form of vasopressin used to replace the hormone in diabetes insipidus. The primary purpose is to decrease urine output by increasing water reabsorption in the kidneys, thereby reducing excessive urination and preventing dehydration. Choice A is incorrect as desmopressin actually decreases urine output. Choice B is incorrect as desmopressin does not directly affect blood sugar levels. Choice D is incorrect as desmopressin does not primarily lower blood pressure.
A patient with chronic kidney disease (CKD) is prescribed erythropoietin. What is the primary action of this medication?
- A. Stimulate white blood cell production
- B. Increase platelet count
- C. Promote red blood cell production
- D. Enhance clotting factor production
Correct Answer: C
Rationale: The correct answer is C: Promote red blood cell production. Erythropoietin is a hormone that stimulates the production of red blood cells in the bone marrow. This is crucial for patients with CKD who often develop anemia due to decreased erythropoietin production.
A: Stimulating white blood cell production is the function of other medications, such as colony-stimulating factors, not erythropoietin.
B: Erythropoietin does not have an effect on platelet count.
D: Enhancing clotting factor production is not the primary action of erythropoietin.