Nokea
A client who is recovering from an appendectomy is receiving narcotics. Earlier, the nurse witnessed the client's family pushing the pain pump. What should the nurse implement?
- A. Check client's level of consciousness
- B. Instruct the family not to push the button
- C. Stop the client's basal infusion
- D. Administer a narcotic reversal medication
Correct Answer: B
Rationale: Instructing the family not to push the button is necessary to prevent the client from receiving an excessive amount of narcotics, ensuring the safe and appropriate use of the pain pump. Educating the family on the proper use of the pump helps maintain the client's pain management within prescribed limits and prevents accidental overdosing.
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A client arrives to the emergency department experiencing diabetic ketoacidosis (DKA). The healthcare provider prescribes an insulin intravenous drip. Which type of insulin should the nurse locate for the registered nurse to mix into the intravenous fluids?
- A. Isophane
- B. Glargine
- C. Regular
- D. Detemir
Correct Answer: C
Rationale: The correct insulin type for the nurse to mix into the intravenous fluids is regular insulin. In the scenario of diabetic ketoacidosis (DKA), rapid reduction of blood glucose levels is crucial. Regular insulin has a fast onset of action, making it suitable for intravenous administration to address the high blood sugar levels seen in DKA. Isophane, Glargine, and Detemir are not appropriate choices for intravenous administration in this emergency situation as they are intermediate-acting or long-acting insulins.
A client with amyotrophic lateral sclerosis (ALS) has been taking riluzole for two weeks. The nurse notes that the client remains weak with observable muscle atrophy. What action should the nurse take?
- A. Explain that the medication may take time to show improvement in symptoms
- B. Withhold the medication and notify the healthcare provider
- C. Advise the client to undergo liver function tests
- D. Document the assessment findings in the electronic health record
Correct Answer: D
Rationale: In this scenario, the nurse's priority is to document the assessment findings in the electronic health record. This action is crucial for maintaining an accurate record of the client's health status and can provide valuable information for the healthcare team. Withholding medication or advising additional tests should only be done after consulting with the healthcare provider based on the documented assessment findings.
A client with diabetes mellitus type 2 is prescribed saxagliptin. The nurse should include which instruction in the client's teaching plan?
- A. Report any signs of pancreatitis to the healthcare provider.
- B. Take this medication with meals.
- C. Avoid alcohol while taking this medication.
- D. Report any signs of heart failure to the healthcare provider.
Correct Answer: A
Rationale: When a client with diabetes mellitus type 2 is prescribed saxagliptin, it is crucial to instruct them to report any signs of pancreatitis to the healthcare provider. Saxagliptin can lead to pancreatitis as a side effect, making it essential for clients to be vigilant about recognizing and reporting any related symptoms promptly for timely intervention and management.
A client with asthma is prescribed montelukast. The nurse should instruct the client that this medication is used for which purpose?
- A. Immediate relief of acute asthma attacks
- B. Long-term control of asthma symptoms
- C. Treatment of exercise-induced bronchospasm
- D. Immediate relief of allergic rhinitis symptoms
Correct Answer: B
Rationale: Montelukast is a leukotriene receptor antagonist used for the long-term control of asthma symptoms by reducing inflammation in the airways. It is not typically used for immediate relief during acute asthma attacks, where short-acting bronchodilators are more appropriate. Montelukast does not specifically target exercise-induced bronchospasm or allergic rhinitis symptoms.
A client with asthma is receiving long-term glucocorticoid therapy. The nurse includes a risk for impaired skin integrity on the client's problem list. What is the rationale for including this problem?
- A. Abnormal fat deposits impair circulation
- B. Frequent diarrhea can lead to skin issues
- C. Thinned skin bruises easily
- D. Decreased serum glucose prolongs healing time
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.