A client is receiving continuous IV nitroprusside for severe hypertension. Which action should the nurse take?
- A. Keep calcium gluconate at the bedside.
- B. Monitor blood pressure every 2 hours.
- C. Limit IV exposure to light.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct action for the nurse to take is to limit IV exposure to light. Nitroprusside is light-sensitive, and exposure to light can lead to its degradation, potentially reducing its efficacy in treating severe hypertension. Keeping calcium gluconate at the bedside (Choice A) is not directly related to managing nitroprusside infusion. While monitoring blood pressure every 2 hours (Choice B) is important in managing hypertension, it is not the immediate action required to ensure medication efficacy. Attaching an inline filter to the IV tubing (Choice D) may help filter particles but does not address the critical concern of light sensitivity associated with nitroprusside administration.
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A nurse is caring for a client who has a new prescription for warfarin. Which of the following laboratory tests should the nurse use to monitor the client's therapeutic response to the medication?
- A. INR
- B. aPTT
- C. Platelet count
- D. Hemoglobin A1C
Correct Answer: A
Rationale: The correct answer is A: INR. The INR (International Normalized Ratio) is the laboratory test used to monitor the therapeutic response of warfarin. It helps ensure that the client's clotting time is within the desired range to prevent complications such as excessive bleeding or clotting. Choice B, aPTT (Activated Partial Thromboplastin Time), is not typically used to monitor warfarin therapy but rather for assessing heparin therapy. Choice C, Platelet count, assesses the number of platelets in the blood and is not specifically used to monitor warfarin therapy. Choice D, Hemoglobin A1C, is a test used to monitor long-term blood sugar control in diabetic patients and is not relevant to monitoring warfarin therapy.
A client who has a new prescription for prednisone is being discharged. Which of the following client statements indicates an understanding of the teaching?
- A. I should take this medication with food.
- B. I will need to take this medication for the rest of my life.
- C. I should avoid crowded places while taking this medication.
- D. I will take this medication until my symptoms resolve.
Correct Answer: C
Rationale: The correct answer is C. Clients taking prednisone should avoid crowded places to reduce the risk of infection due to immunosuppression. Choice A is incorrect because prednisone should be taken with food to reduce stomach upset. Choice B is incorrect as prednisone is usually prescribed for a specific duration and not for life. Choice D is incorrect because prednisone should be taken as prescribed by the healthcare provider, which may not always align with symptom resolution.
A nurse is teaching a client who has hypertension about managing blood pressure. Which of the following statements should the nurse make?
- A. Increase your intake of red meat to manage your blood pressure.
- B. You should avoid drinking alcohol while taking this medication.
- C. Exercise for at least 30 minutes most days of the week.
- D. Limit your fluid intake to 3 liters per day.
Correct Answer: C
Rationale: The correct statement is C: 'Exercise for at least 30 minutes most days of the week.' Regular exercise is essential in managing blood pressure as it helps improve cardiovascular health. Choice A is incorrect as increasing red meat intake can be detrimental due to its high saturated fat content, which can negatively impact blood pressure. Choice B is not directly related to managing blood pressure unless the medication interacts negatively with alcohol. Choice D, limiting fluid intake to 3 liters per day, is not a general recommendation for managing blood pressure unless specifically advised by a healthcare provider.
A nurse is providing discharge teaching to a client who has a new prescription for albuterol. Which of the following instructions should the nurse include?
- A. You should take this medication at bedtime.
- B. You might experience palpitations while taking this medication.
- C. You should rinse your mouth after using this medication.
- D. You should avoid eating before taking this medication.
Correct Answer: C
Rationale: The correct answer is C: 'You should rinse your mouth after using this medication.' When providing discharge teaching for a client prescribed albuterol, the nurse should include the instruction to rinse the mouth after each use. This is important to prevent dry mouth and oral infections. Choice A is incorrect as albuterol is usually taken during the day to manage symptoms, not at bedtime. Choice B is incorrect as palpitations are not a common side effect of albuterol. Choice D is incorrect as there is no specific requirement to avoid eating before taking albuterol.
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?
- A. Position the client supine.
- B. Prepare an IV bolus of dextrose 5% in water.
- C. Administer methylergonovine IM.
- D. Administer calcium gluconate IV.
Correct Answer: D
Rationale: Administering calcium gluconate IV is the correct action when a client displays toxicity from magnesium sulfate. Calcium gluconate is used as the antidote for magnesium sulfate toxicity as it counteracts the effects. Positioning the client supine (Choice A) is not the immediate action needed. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Administering methylergonovine IM (Choice C) is used in postpartum hemorrhage, not for magnesium sulfate toxicity.
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