Nokea
A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?
- A. Stores the medication at room temperature.
- B. Primes the inhaler with 7 pumps.
- C. Attaches spacer device to the inhaler.
- D. Rinses the mouth after each use.
Correct Answer: B
Rationale: Priming an ipratropium inhaler with 7 pumps is excessive; typically, 2–3 pumps are needed if unused for a period. Room temperature storage, spacer use, and mouth rinsing are correct practices.
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A client is receiving miotics for the treatment of open-angle glaucoma. The nurse determines that a priority nursing problem is 'risk for injury.' This nursing problem is based on which etiology?
- A. Increased frequency of lacrimation.
- B. Decreased night vision.
- C. Increased sensitivity to light.
- D. Diminished color perception.
Correct Answer: B
Rationale: Miotics constrict the pupil, reducing night vision and increasing injury risk in low-light conditions. Lacrimation, photophobia, and color perception changes are less directly linked to injury risk.
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 75-year-old female who was admitted to the preop area to prepare for pacemaker insertion. She states that she needs this procedure because her heart rate has been very low, she feels tired all the time, and she has fainted once due to low heart rate. She has a history of worsening symptomatic bradycardia and atrial fibrillation controlled by medication. She has been off anticoagulants for four days to prepare for the procedure.
Nurses notes
0700
Laboratory specimens have been drawn and completed during a preadmission visit. After changing clothes and settling into bed, client was placed on continuous monitoring. Admission process completed.
0800
Peripheral IV (PIV) started in right antecubital with 20 gauge catheter. IV fluids of 0.9% sodium chloride started at 50 mL/hr. Cardiac surgeon in to see client and answers questions about the procedure.
0830
Client reports no known allergies. Vancomycin 1 gram in 250 ml 0.9% sodium chloride started at 125 mL/hr as endocarditis prophylaxis.
0840
Awaiting transfer to operating room (OR).
Vancomycin infusing at 125 mL/hr.
0845: The client says, "I don't feel well." Assessment reveals dizziness, headache, burning sensation on extremities, and red color on face and extremities. Blood pressure is 108/46 mmHg. Vancomycin infusion was stopped. The surgeon was notified.
0850: The client has flushing and redness over her entire body with hives developing. She complains of feeling hot and nauseous. Cool cloths were applied to her face and extremities. She is restless in bed. IVF of NS is running.
0900
Heart rate 90 beats/minute, blood pressure 110/60 mm Hg. Surgeon remains at bedside.
0915
Heart rate 60 beats/minute, blood pressure 120/70 mm Hg. Appears more relaxed - not thrashing about bed. Skin color remains red: reports itching
resulting in symptoms of skin color0945
Heart rate 52 beats/minute, blood pressure 128/72 mm Hg. To OR for pacemaker placement.
1100
Returned from OR. Heart rate 64 beats/minute, blood pressure 118/68 mm Hg, temperature 97.4° F(36.3° C) orally. Verbalizes not being able to stop shaking and pounding chest pain. Short of breath. Skin color is dark pink. Headache increasing and has nausea. Surgeon at bedside. Chest x-ray done. Echocardiogram performed..
Orders
0800
Start peripheral IV
Vancomycin 1 gram in 250 mL 0.9% sodium chloride
Flowsheet
0700
Vital Sign
• Temperature 97.6° F (36.4° C) orally
• Heart rate 44 beats/minute
• Respiratory rate 18 breaths/minute
• Blood pressure 136/50 mm Hg
The nurse is preparing the client's plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.
- A. Dosage in safe range
- B. Peripheral IV in large vein
- C. No known allergies
- D. Used for prophylaxis
- E. Blood urea nitrogen 17 mg/dL (6.07 mmol/L)
- F. Potassium 4.4 mEq/L (4.4 mmol/L)
Correct Answer: A,B,C,E
Rationale: A: Safe dosage prevents toxicity. B: Large vein reduces phlebitis risk. C: No allergies avoids reactions. E: Normal BUN indicates renal function for vancomycin excretion. D and F are less directly related to safety.
A client with cystitis receives a prescription for phenazopyridine. Which information should the nurse explain to the client about its therapeutic effect?
- A. Provides an analgesic effect for irritated bladder mucosa.
- B. Eliminates urinary bacteria.
- C. Calms spasms in the urinary tract.
- D. Use the medication after voiding after sexual intercourse.
Correct Answer: A
Rationale: Phenazopyridine is a urinary analgesic that relieves pain, burning, and discomfort from irritated bladder mucosa in cystitis. It does not have antibacterial properties, calm spasms, or require specific timing related to sexual intercourse.
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.