Nokea
A client who experiences migraine headaches reports having fewer headaches since using the herbal remedy feverfew. Which information is most important for the nurse to include in a teaching plan for this client?
- A. Increased anxiety and nervousness have been reported by those taking feverfew.
- B. Those with allergies to chamomile, ragweed, or yarrow should not take feverfew.
- C. Abdominal pain, gas, nausea, vomiting, and diarrhea can occur when taking feverfew.
- D. Feverfew may interact with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).
Correct Answer: B
Rationale: Feverfew can cause allergic reactions in individuals allergic to chamomile, ragweed, or yarrow, making this critical to prevent serious reactions. Anxiety, GI effects, or NSAID interactions are less urgent.
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History and physical
The client is a 26-year-old female with acute appendicitis. She has a 12 year history of type 1 diabetes mellitus and no other significant medical history. The appendectomy was completed without issue, and the client will be admitted to the surgical floor to recover.
Nurses notes
0730
Admitted the client. She is awake and alert. She rates her pain 2 on a 0 to 10 pain scale. Her pulses are equal bilaterally. Heart rate is 76 beats/minute, normal sinus rhythm. Her oxygen saturation is 100% on room air. She has a gauze dressing over her surgical site, which is clean and dry. Her temperature is 98.5° F (37.0° C) orally. She urinated 50 mL upon arrival in the unit and is reporting she
Lab results
Blood glucose 279mg/dl
Orders
Admit to the surgical floor
• Dextrose 5% and 0.9% sodium chloride IV to infuse at 125 mL/hr
Advance diet as tolerated
• Insulin glargine 12 units SUBQ every 24 hours
. Ceftriaxone 2 gram IV piggy back (IVPB) every
24 hours for 3 days, first dose given in surgery
It is 1800, and the client has a scheduled dose of insulin glargine due. The client has a regular diet tray ordered with 60 carbohydrates. The tray has not yet arrived in the room. For each nursing action below, click to specify if the action is indicated, contraindicated or nonessential.Each row must have one option selected.
- A. Give insulin lispro 4 units: Contraindicated
- B. Verify that the client can count carbohydrates: Nonessential
- C. Mix the insulin lispro and insulin glargine in one syringe: Contraindicated
- D. Give insulin glargine 12 units: Indicated
Correct Answer:
Rationale: A: Lispro is contraindicated without meal intake to avoid hypoglycemia. B: Carb counting is nonessential for scheduled glargine. C: Mixing lispro and glargine is contraindicated. D: Glargine is indicated as scheduled.
The nurse prepares to administer a scheduled dose of labetalol PO to a client with hypertension. The client's vital signs are a temperature of 99° F (37.2° C), a heart rate of 48 beats/minute, respirations of 16 breaths/minute, and a blood pressure of 150/90 mm Hg. Which action should the nurse take?
- A. Apply a telemetry monitor before administering the dose.
- B. Assess for orthostatic hypotension before administering the dose.
- C. Administer the dose and monitor the client's blood pressure regularly.
- D. Withhold the scheduled dose and notify the healthcare provider.
Correct Answer: D
Rationale: A heart rate of 48 beats/minute indicates bradycardia, a concern with labetalol (a beta-blocker). Withholding the dose and notifying the provider is appropriate to prevent worsening bradycardia.
The nurse is caring for a client with atrial fibrillation who receives a prescription for warfarin. The international normalized ratio (INR) is 2.8. Which action should the nurse take?
- A. Obtain another blood sample.
- B. Give the next scheduled dose.
- C. Monitor for signs of bleeding.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: An INR of 2.8 is within the therapeutic range for atrial fibrillation, but monitoring for bleeding is critical as a routine precaution. Repeating the sample, giving the dose, or notifying the provider are less immediate.
During a home visit, the nurse assesses a client with Alzheimer's disease who recently started a new prescription for rivastigmine. The caregiver reports that the client seems to be thinking more clearly but is not sleeping well at night. Which action should the nurse take?
- A. Advise the caregiver that the purpose of the medication is to promote sleep, so a change in medication may be needed.
- B. Explain to the caregiver that insomnia is a common and temporary side effect when the medication is first started.
- C. Instruct the caregiver to withhold the medication until the dosage can be decreased to ensure the client's safety.
- D. Notify the healthcare provider that the dosage of the medication may need to be increased to manage the client's insomnia.
Correct Answer: B
Rationale: Insomnia is a common, often temporary side effect of rivastigmine. Explaining this reassures the caregiver. Rivastigmine is for cognition, not sleep, and withholding or increasing the dose is inappropriate without provider guidance.
A client with a cold is taking the antitussive medication benzonatate. Which assessment information indicates to the nurse that the medication is effective?
- A. Denies having coughing spells.
- B. Able to sleep through the night.
- C. Expectorating bronchial secretions.
- D. Reports reduced nasal discharge.
Correct Answer: B
Rationale: Benzonatate suppresses cough, and sleeping through the night indicates effective cough control. Denying coughing spells is less specific, expectoration relates to expectorants, and nasal discharge is unrelated to antitussive effects.