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A client with Parkinson’s disease who is taking carbidopa/levodopa reports that the urine appears to be darker in color. What action should the nurse take?
- A. Encourage an increase in oral intake.
- B. Explain that the color change is normal.
- C. Obtain a specimen for a urine culture.
- D. Measure the client’s urinary output.
Correct Answer: B
Rationale: Carbidopa/levodopa can darken urine (B), a benign side effect. Increased fluids (A) or urine culture (C) are unnecessary unless other symptoms arise. Measuring output (D) doesn’t address the color change.
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A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this client’s plan of care?
- A. Replace salt with a salt substitute.
- B. Cover your skin before going outside.
- C. Limit intake of high-potassium foods.
- D. Monitor skin for excessive bruising.
Correct Answer: C
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia. Limiting high-potassium foods (C) prevents this risk. Salt substitutes (A) often contain potassium, worsening hyperkalemia. Sun protection (B) and bruising (D) are unrelated to spironolactone’s primary risks.
Which intervention is most important for the nurse to implement for a client who is receiving insulin lispro?
- A. Assess for hypoglycemia between meals.
- B. Check blood glucose levels every six hours.
- C. Provide meals at the same time this insulin is given.
- D. Keep an oral liquid or glucose source available.
Correct Answer: C
Rationale: Insulin lispro, a rapid-acting insulin, peaks quickly and should be given with meals (C) to match food intake and prevent hypoglycemia. Assessing for hypoglycemia (A) and keeping glucose sources (D) are important but secondary. Six-hour glucose checks (B) are too infrequent.
After administering five doses of filgrastim, the nurse observes that the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3. What action should the nurse take?
- A. Inform the patient that the medication has been effective.
- B. Review the patient’s culture and sensitivity reports.
- C. Implement neutropenic precautions.
- D. Assess the patient’s vital signs.
Correct Answer: A
Rationale: Filgrastim stimulates white blood cell production. An increase from 2,500/mm^3 to 5,000/mm^3 (A) indicates effectiveness, and the patient should be informed. Culture reports (B) are unrelated to filgrastim’s action. Neutropenic precautions (C) are unnecessary with improved counts. Vital signs (D) don’t directly assess filgrastim’s efficacy.
A female client with multiple sclerosis reports having less fatigue and improved memory since she began using the herbal supplement, ginkgo biloba. What is the most important information for the nurse to include in the teaching plan for this client?
- A. Nausea and diarrhea can occur when using this supplement.
- B. Ginkgo biloba use should be limited and not taken during pregnancy.
- C. Aspirin and non-steroidal anti-inflammatory drugs interact with ginkgo.
- D. Anxiety and headaches increase with the use of ginkgo biloba.
Correct Answer: C
Rationale: Ginkgo biloba increases bleeding risk, especially with aspirin/NSAIDs (C), a critical interaction for safety. Nausea/diarrhea (A) and anxiety/headaches (D) are less severe. Pregnancy restrictions (B) are relevant but secondary unless applicable.
A patient is receiving a secondary infusion of azithromycin 500 mg in 500 mL of normal saline (NS) to be infused over 2 hours. The intravenous (IV) administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion?
Correct Answer: 42
Rationale: Infusion rate: 500 mL / 2 hr = 250 mL/hr. Drops per minute: (250 mL/hr × 10 gtt/mL) / 60 min = 41.67, rounded to 42 gtt/min. This ensures accurate delivery of azithromycin.