Nokea
A client is receiving morphine sulfate for pain management. Which assessment finding requires immediate action?
- A. Constipation
- B. Drowsiness
- C. Respiratory rate of 10 breaths per minute
- D. Nausea
Correct Answer: C
Rationale: A respiratory rate of 10 breaths per minute indicates respiratory depression, a serious side effect of morphine sulfate that can lead to respiratory compromise and requires immediate intervention. Constipation, drowsiness, and nausea are common side effects of morphine but are not immediately life-threatening compared to respiratory depression.
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The healthcare provider prescribes exenatide (Byetta) for a client with type 1 diabetes mellitus who takes insulin. What is the appropriate intervention for the nurse?
- A. Administer the medication within 60 minutes before the morning and evening meal.
- B. Withhold the medication and question the prescription with the healthcare provider.
- C. Monitor the client for gastrointestinal side effects after administration of the medication.
- D. Withdraw the insulin from the Penlet into an insulin syringe to prepare for administration.
Correct Answer: B
Rationale: Exenatide (Byetta) is specifically indicated for the treatment of type 2 diabetes mellitus and is not recommended for clients with type 1 diabetes mellitus who are taking insulin. Therefore, the appropriate intervention for the nurse is to withhold the medication and question the prescription with the healthcare provider to ensure the safety and appropriateness of the treatment plan for the client.
A client is receiving furosemide (Lasix) and is being discharged. What should the nurse include in the teaching plan?
- A. Avoid potassium-rich foods.
- B. Take the medication in the morning.
- C. Change positions slowly to prevent dizziness.
- D. Maintain a restricted fluid intake.
Correct Answer: C
Rationale: Furosemide (Lasix) is a diuretic that can lead to orthostatic hypotension, causing dizziness. Instructing the client to change positions slowly can help prevent this adverse effect. It is important for the client to consume foods rich in potassium to prevent hypokalemia. Taking furosemide in the morning helps reduce the need for frequent urination at night. Encouraging the client to maintain an adequate fluid intake is crucial to prevent dehydration while on this medication.
A client taking ethambutol (Myambutol) understands the instructions provided by the nurse if the client states that he or she will immediately report:
- A. Impaired sense of hearing
- B. Problems with visual acuity
- C. Gastrointestinal (GI) side effects
- D. Orange-red discoloration of body secretions
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is taking docusate sodium (Colace). The nurse monitors which of the following to determine whether the client is experiencing a therapeutic effect from this medication?
- A. Abdominal pain
- B. Reduction in steatorrhea
- C. Hematest-negative stools
- D. Regular bowel movements
Correct Answer: D
Rationale: The therapeutic effect of docusate sodium (Colace) is to soften stools and promote regular bowel movements, making option D the correct choice. Monitoring for regular bowel movements would indicate that the medication is working as intended by relieving or preventing constipation. Options A, B, and C are not directly related to the therapeutic effect of docusate sodium.
A healthcare professional is monitoring a client who is receiving intravenous amphotericin B. Which of the following should prompt the healthcare professional to notify the healthcare provider immediately?
- A. Fever
- B. Headache
- C. Nausea
- D. Oliguria
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.