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A client with Addison's disease is being admitted for a total hip arthroplasty. The client takes hydrocortisone for Addison's disease. What is the nurse's priority action?
- A. Administering a supplemental dose of hydrocortisone
- B. Instructing the client about coughing and deep breathing
- C. Collecting additional information from the client about his history of Addison's disease
- D. Inserting an indwelling urinary catheter
Correct Answer: A
Rationale: The nurse's priority in this situation is to administer a supplemental dose of hydrocortisone. Clients with Addison's disease taking hydrocortisone are at risk of acute adrenal insufficiency during times of stress such as surgery. Administering supplemental doses of hydrocortisone helps prevent acute adrenal insufficiency (adrenal crisis) in these situations, making it the priority action to ensure the client's safety. Instructing the client about coughing and deep breathing is important postoperatively but not the priority at this time. Collecting additional information about the client's history of Addison's disease is important but not the priority action before surgery. Inserting an indwelling urinary catheter is not the priority in this situation.
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A healthcare provider is preparing to administer an Opioid agonist to a client who has acute pain. Which of the following complications should the provider monitor?
- A. Urinary retention
- B. Tachypnea
- C. Hypertension
- D. Irritating cough
Correct Answer: A
Rationale: The correct answer is urinary retention. Opioid agonists like morphine can suppress the awareness of bladder fullness, leading to urinary retention. This complication can result in significant discomfort and potential urinary tract issues if not promptly addressed. Tachypnea (increased respiratory rate) is a common side effect of opioids but is not a specific complication related to urinary retention. Hypertension is not typically associated with opioid agonists and is more commonly seen with opioid antagonists. An irritating cough is not a known complication of opioid agonists and is not directly related to the effect opioids have on the urinary system.
A client has a new prescription for Lithium Carbonate. When teaching the client about ways to prevent Lithium toxicity, the client should be advised to do which of the following?
- A. Avoid using acetaminophen for headaches.
- B. Restrict intake of foods rich in sodium.
- C. Decrease fluid intake to less than 1,500 mL daily.
- D. Limit aerobic activity in hot weather.
Correct Answer: D
Rationale: The correct answer is to advise the client to limit aerobic activity in hot weather. Aerobic activity in hot weather can lead to excessive sweating, potentially causing sodium and water depletion, which can increase the risk of Lithium toxicity. It is important for clients taking Lithium to maintain adequate hydration and sodium levels to prevent toxicity. Choices A, B, and C are incorrect. Avoiding acetaminophen for headaches is not directly related to Lithium toxicity. Restricting intake of foods rich in sodium is not recommended because adequate sodium levels are necessary to prevent Lithium toxicity. Decreasing fluid intake to less than 1,500 mL daily is also not advisable as adequate hydration is important to prevent Lithium toxicity.
A client requests information on the use of Feverfew. Which of the following responses should the nurse make?
- A. It is used to treat skin infections.
- B. It can decrease the frequency of migraine headaches.
- C. It can lessen nasal congestion in the common cold.
- D. It can relieve nausea of morning sickness during pregnancy.
Correct Answer: B
Rationale: The correct response is B: Feverfew is commonly used to decrease the frequency of migraine headaches. However, it is important to note that it has not been proven to relieve an existing migraine headache. Choices A, C, and D are incorrect as Feverfew is not typically used for treating skin infections, lessening nasal congestion in the common cold, or relieving nausea of morning sickness during pregnancy.
A healthcare professional is preparing to initiate IV therapy for an older adult client. Which of the following actions should the professional plan to take?
- A. Use an electric shaver to remove excess hair on the extremity.
- B. Select the antecubital area to insert the IV catheter.
- C. Distend the veins by using a blood pressure cuff.
- D. Instruct the client to keep the extremity still during the procedure.
Correct Answer: C
Rationale: Distending the veins using a blood pressure cuff is essential for facilitating visualization and access to the veins during IV catheter insertion. This technique helps healthcare professionals identify suitable veins, reducing the risk of complications like infiltration or hematoma formation. Using an electric shaver to remove hair on the extremity (Choice A) may increase the risk of micro-cuts and introduce infection. Selecting the antecubital area (Choice B) may not always be appropriate, as vein condition and accessibility vary among older adult clients. Instructing the client to keep the extremity still (Choice D) is important but is not directly related to preparing for IV therapy.
A child is prescribed Amoxicillin 20 mg/kg/day PO to be administered every 12 hr. The child weighs 44 lb. The available medication is amoxicillin suspension 250 mg/5 mL. How many mL should be given per dose?
- A. 4 mL
- B. 5 mL
- C. 6 mL
- D. 3 mL
Correct Answer: A
Rationale: To calculate the dosage per administration: Convert the weight to kg (44 lb / 2.2 lb/kg = 20 kg). Then, (20 mg/kg/day x 20 kg) / 2 (for every 12 hr dosing) = 200 mg per dose. (200 mg / 250 mg) x 5 mL = 4 mL per dose. Therefore, the nurse should administer 4 mL of amoxicillin suspension per dose. Choice B, 5 mL, is incorrect because the calculation shows that 4 mL is the correct dose. Choices C and D are also incorrect as they are not in line with the calculated dosage based on the weight of the child and the concentration of the medication.