Nokea
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.
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History and physical
POD 5
1015
The client is alert and oriented. Rates her pain a 3 on a 0 to 10 pain scale. The client says that she has fullness in her abdomen. Heart sounds are regular and rhythmic. Pulses 1+ in all extremities and equal. Her last bowel movement was POD 2. Healthcare provider notified. The client voided 150 mL of urine.
1100
Bisacodyl suppository given as prescribed.
Reported slight rectal burning when administered.
Nurses notes
POD 5
1015
The client is alert and oriented. Rates her pain a 3 on a 0 to 10 pain scale. The client says that she has fullness in her abdomen. Heart sounds are regular and rhythmic. Pulses 1+ in all extremities and equal. Her last bowel movement was POD 2. Healthcare provider notified. The client voided 150 mL of urine.
1100
Bisacodyl suppository given as prescribed.
Reported slight rectal burning when administered.
1200
Rates her pain a 7 on a 0 to 10 pain scale. Pulses 1+ in all extremities and equal. Morphine given as prescribed. She asked to use the restroom but felt dizzy. Voided 600 mL urine in the bedpan.
Flowsheet
Vital Signs
POD 5
1015
Temperature 97.2° F (36.2° C) orally
Heart rate 77 beats/minute
Respiratory rate 14 breaths/minute
Blood pressure 119/75 mm Hg
1200
• Temperature 97° F (36.1° C) orally
Review H and P, nurse's notes, flow sheet, and prescriptions. Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have only one option selected.
- A. Reported slight rectal burning sensation: Non-therapeutic side effect
- B. Large, soft stool: Therapeutic result
- C. Dizziness: Non-therapeutic side effect
- D. Pain level of 3 on a 0 to 10 pain scale: Unrelated finding
- E. 600ml of urine: Unrelated finding
- F. Abdomen soft and flat: Unrelated finding
- G. Respiratory rate 13 breaths/min: Unrelated finding
Correct Answer:
Rationale: The question refers to bisacodyl, not lactulose. A: Rectal burning is a bisacodyl side effect. B: Soft stool is the therapeutic effect. C: Dizziness may relate to morphine, not bisacodyl. D, E, F, G: Pain, urine output, abdomen, and respiratory rate are unrelated to bisacodyl.
The nurse is administering sucralfate to a client with stomatitis secondary to chemotherapy. The client wants to take the medication after breakfast. How should the nurse respond?
- A. Explain the need to take the medication at least 1 hour before meals.
- B. Allow the client to take the medication up to 1 hour after breakfast.
- C. Document the client's refusal of the medication at this time.
- D. Instruct the client to take it when the meal tray is delivered.
Correct Answer: A
Rationale: Sucralfate must be taken on an empty stomach, at least 1 hour before meals, to effectively coat the mucosa. Post-meal administration, refusal documentation, or meal-time dosing are incorrect.
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
According to the information gathered in the nurse's assessment, the nurse should prepare to give the client [Dropdown 1] and [Dropdown 2].
- A. Insulin glargine
- B. A snack
- C. Glucagon
- D. Ceftriaxone
- E. Juice
- F. A glass of Water
Correct Answer: A,B
Rationale: A blood glucose of 279 mg/dL requires insulin glargine for correction, and a snack prevents hypoglycemia post-insulin.
When administering zolpidem to an older client, which computer documentation indicates that the desired outcome has been achieved?
- A. Exhibits fewer emotional outbursts.
- B. Improved ability to concentrate.
- C. Decreased episodes of incontinence.
- D. Sleeps soundly through the night.
Correct Answer: D
Rationale: Zolpidem is a sedative for insomnia, and sleeping soundly through the night indicates its effectiveness. Emotional outbursts, concentration, and incontinence are not primary targets of zolpidem.
A client with a history of smoking cigarettes for many years arrives at the clinic and expresses a desire to stop smoking. The client receives a prescription for bupropion to reduce nicotine cravings. Which information should the nurse include in the discharge teaching?
- A. Administer each dose with at least 8 ounces of water.
- B. Consume tyramine-free foods while taking the medicine.
- C. Be aware that difficulty sleeping and weight loss may occur.
- D. Notify the healthcare provider if experiencing changes in taste.
Correct Answer: C
Rationale: Bupropion may cause insomnia and weight loss, which are important side effects for the client to understand. Water intake, tyramine-free diets, and taste changes are not primary concerns with bupropion.