A client is to receive Tetracaine prior to a Bronchoscopy. Which of the following actions should the nurse include in the plan of care?
- A. Keep the client NPO until the pharyngeal response returns.
- B. Monitor the insertion site for a hematoma.
- C. Palpate the bladder to detect urinary retention.
- D. Maintain the client on bed rest for 12 hours following the procedure.
Correct Answer: A
Rationale: The correct action the nurse should include in the plan of care is to keep the client NPO until the pharyngeal response returns. This is important to prevent aspiration until the client's normal pharyngeal sensation is restored, typically within about 1 hour after the procedure. Monitoring the insertion site for a hematoma, palpating the bladder, and maintaining the client on bed rest are not directly related to the administration of Tetracaine prior to a Bronchoscopy.
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When caring for a client prescribed Digoxin, which of the following laboratory values should the nurse monitor to assess for potential toxicity?
- A. Sodium
- B. Potassium
- C. Magnesium
- D. Calcium
Correct Answer: B
Rationale: When a client is prescribed Digoxin, monitoring potassium levels is crucial as hypokalemia can increase the risk of Digoxin toxicity. Low potassium levels can potentiate the effects of Digoxin on the heart, leading to toxicity. Therefore, regular monitoring of potassium levels helps in preventing adverse effects and ensuring the safe use of Digoxin.
When reviewing a client's health record, a nurse notes a new prescription for Lisinopril 10 mg PO once daily. The nurse should identify this as which type of prescription?
- A. Single
- B. Stat
- C. Routine
- D. Standing
Correct Answer: C
Rationale: A routine prescription indicates medications to be administered on a regular schedule without a termination date or a specific number of doses. In this case, Lisinopril 10 mg PO once daily falls under a routine prescription, meaning the nurse will administer this medication daily until the provider discontinues it.
A nurse is teaching a client who has breast cancer about the adverse effects of chemotherapy. Which of the following statements should the nurse include?
- A. You should use a soft-bristled toothbrush to prevent bleeding.'
- B. You should take aspirin for minor aches and pains.'
- C. You should avoid contact with individuals who recently received live virus vaccines.'
- D. You should consume a diet low in protein to reduce the risk of renal damage.'
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During transfusion of a unit of whole blood, a nurse is assessing a client who develops a cough, shortness of breath, elevated blood pressure, and distended neck veins. The nurse should anticipate a prescription for which of the following medications?
- A. Epinephrine
- B. Lorazepam
- C. Furosemide
- D. Diphenhydramine
Correct Answer: C
Rationale: The client's symptoms indicate circulatory overload, which can occur during blood transfusions. Furosemide, a loop diuretic, is commonly prescribed in such cases to help relieve manifestations of circulatory overload by promoting diuresis and reducing fluid volume. Epinephrine is used for severe allergic reactions, lorazepam for anxiety or seizures, and diphenhydramine for mild allergic reactions or as a sedative.
A client is prescribed Diltiazem. Which of the following findings should the nurse monitor?
- A. Tachycardia
- B. Bradycardia
- C. Hypertension
- D. Hyperkalemia
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.