Nokea
A client with atrial fibrillation is receiving digoxin (Lanoxin). Which of these assessments is most important for the nurse to perform?
- A. Monitor blood pressure every 4 hours
- B. Measure apical pulse prior to administration
- C. Maintain accurate intake and output records
- D. Record an EKG strip after administration
Correct Answer: B
Rationale: Measure apical pulse prior to administration. Digitoxin decreases conduction velocity through the AV node and prolongs the refractory period. If the apical heart rate is less than 60 beats/minute, withhold the drug. The apical pulse should be taken with a stethoscope so that there will be no mistake about what the heart rate actually is.
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The client is to receive 3,000 mg of medication daily in a divided dose every eight (8) hours. The medication comes 500 mg per tablet. How many tablets will the nurse administer at each dose?
Correct Answer: 2
Rationale: Daily dose: 3,000 mg / 3 doses (every 8 hr) = 1,000 mg/dose. Tablets: 1,000 mg / 500 mg/tablet = 2 tablets per dose.
The male client with a chronic urinary tract infection is prescribed trimethoprim-sulfamethoxazole (Bactrim). Which statement indicates the client needs more teaching?
- A. I will drink six (6) to eight (8) glasses of water a day.
- B. I am going to have to take this medication forever.
- C. I can stop taking this medication if there is no more burning.
- D. I may get diarrhea with this medication, but I can take Imodium.
Correct Answer: C
Rationale: Stopping Bactrim when symptoms resolve risks incomplete treatment and resistance; full course is needed. Hydration, duration, and diarrhea management are correct.
The nurse is administering an intramuscular (IM) injection to a client. When the nurse aspirates, there is a blood return. What is the most appropriate action for the nurse to take?
- A. Continue to administer the medication
- B. Withdraw the needle and administer in another site
- C. Withdraw the needle, discard the medication, and start over
- D. Change the needle before administering the medication in another site
Correct Answer: C
Rationale: The nurse should not inject medication that has blood in it. Blood may interact with the medication and cause an adverse response.
An adult is hospitalized for an acute attack of gout. Which medication should the nurse expect to administer?
- A. Morphine
- B. Colchicine
- C. Allopurinol
- D. Acetaminophen
Correct Answer: B
Rationale: Colchicine is used to treat acute gout attacks by reducing inflammation, unlike allopurinol, which prevents attacks.
The client with coronary artery disease is prescribed one (1) baby aspirin a day. Which instructions should the nurse provide the client concerning this medication?
- A. Take the medication on an empty stomach.
- B. Do not take Tylenol while taking this drug.
- C. If experiencing joint pain, notify the HCP.
- D. Notify the HCP if stools become dark and tarry.
Correct Answer: D
Rationale: Dark, tarry stools suggest GI bleeding, a serious aspirin side effect, requiring HCP notification. Empty stomach, Tylenol, or joint pain are less critical.