Nokea
A client is receiving dexamethasone (Decadron) therapy. What should the nurse plan to monitor in this client?
- A. Urine output every 4 hours
- B. Blood glucose levels every 12 hours
- C. Neurological signs every 2 hours
- D. Oxygen saturation every 8 hours
Correct Answer: B
Rationale: The drug Decadron increases gluconeogenesis. This may lead to hyperglycemia. Therefore the blood sugar level and acetone production must be monitored.
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The client diagnosed with essential hypertension calls the clinic and tells the nurse she needs something for the flu. Which information should the nurse tell the client?
- A. OTC medications for the flu should not be taken because of your hypertension.
- B. If OTC medications do not relieve symptoms within three (3) days, contact the HCP.
- C. Tell the client to ask the pharmacist to recommend an OTC medication for the flu.
- D. Make an appointment for the client to receive the influenza vaccine.
Correct Answer: B
Rationale: OTC flu medications (e.g., decongestants) may raise BP but can be used cautiously; persistent symptoms warrant HCP contact. Total avoidance, pharmacist reliance, or vaccines are less appropriate.
The client is exhibiting multifocal premature ventricular contractions. Which antidysrhythmic medication should the nurse anticipate the HCP ordering for this dysrhythmia?
- A. Adenosine.
- B. Epinephrine.
- C. Atropine.
- D. Amiodarone.
Correct Answer: D
Rationale: Amiodarone is effective for ventricular dysrhythmias like PVCs, per ACLS guidelines. Adenosine, epinephrine, or atropine are used for other rhythms.
A woman who is receiving cancer chemotherapy exhibits all of the following. Which is most indicative of bone marrow depression?
- A. Alopecia
- B. Petechiae
- C. Stomatitis
- D. Constipation
Correct Answer: B
Rationale: Petechiae indicate low platelets, a sign of bone marrow depression, a common chemotherapy side effect.
A client with an aplastic sickle cell crisis is receiving a blood transfusion and begins to complain of 'feeling hot.' Almost immediately, the client begins to wheeze. What is the nurse's first action?
- A. Stop the blood infusion
- B. Notify the health care provider
- C. Take/record vital signs
- D. Send blood samples to lab
Correct Answer: A
Rationale: Stop the blood infusion. If a reaction of any type is suspected during administration of blood products, stop the infusion immediately, keep the line open with saline, notify the health care provider, monitor vital signs and other changes, and then send a blood sample to the lab.
The nurse is administering an otic drop to the 45-year-old client. Which procedure should the nurse implement when administering the drops?
- A. Place the drops when pulling the ear down and back.
- B. Place the drops when pulling the ear up and back.
- C. Place the drops in the lower conjunctival sac.
- D. Place the drops in the inner canthus and apply pressure.
Correct Answer: B
Rationale: For adults, pulling the ear up and back straightens the ear canal for otic drops. Down/back is for children, others are for ophthalmic drops.