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A client with psychosis is receiving an antipsychotic medication and is continually rubbing the back of the neck. What is the best nursing intervention?
- A. Obtain an extra pillow for the client to use at night.
- B. Give a PRN prescription for benztropine.
- C. Provide the client a heating pad to place on the neck.
- D. Obtain a prescription for physical therapy services.
Correct Answer: B
Rationale: Neck rubbing suggests extrapyramidal symptoms (e.g., dystonia) from antipsychotics. Benztropine (B), an anticholinergic, relieves these symptoms. Pillows (A), heating pads (C), and physical therapy (D) don’t address the cause.
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A client taking atorvastatin has an increased serum creatine phosphokinase (CK) level. What should the nurse assess the client for?
- A. Excessive bruising.
- B. Peripheral edema.
- C. Muscle tenderness.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: Elevated CK with atorvastatin indicates possible myopathy, causing muscle tenderness (C). Bruising (A) is unrelated to CK. Edema (B) suggests other causes. Nausea/vomiting (D) are gastrointestinal side effects, not linked to CK.
A patient is currently on an oral contraceptive and has been prescribed erythromycin. What advice should the nurse provide to the patient?
- A. Utilize an additional form of contraception.
- B. Immediately discontinue the oral contraceptive.
- C. Ensure a 12-hour gap between taking the medications.
- D. Avoid prolonged exposure to direct sunlight.
Correct Answer: A
Rationale: Erythromycin may reduce oral contraceptive efficacy by inducing hepatic metabolism. Using an additional contraceptive method (A) prevents unintended pregnancy. Discontinuing the contraceptive (B) is unnecessary. Timing gaps (C) don’t mitigate the interaction. Sunlight avoidance (D) relates to other antibiotics like tetracycline.
A client with a history of chronic obstructive pulmonary disease (COPD) has been prescribed a new ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?
- A. The client primes the inhaler with 7 pumps.
- B. The client stores the medication at room temperature.
- C. The client rinses their mouth after each use.
- D. The client attaches a spacer device to the inhaler.
Correct Answer: A
Rationale: Ipratropium inhalers require 2-3 priming sprays for new devices, not 7 (A), indicating a need for teaching. Room temperature storage (B), mouth rinsing (C), and spacer use (D) are correct.
When administering medications to a group of patients, which patient should the nurse closely monitor for the development of acute kidney injury (AKI)?
- A. Patient on Vancomycin.
- B. Patient on Sucralfate.
- C. Patient on Lorazepam.
- D. Patient on Digoxin.
Correct Answer: A
Rationale: Vancomycin (A) is nephrotoxic and requires monitoring for AKI, especially with high doses or prolonged use. Sucralfate (B) protects the stomach, not kidneys. Lorazepam (C) and digoxin (D) have minimal renal toxicity risks.
A patient has received a new prescription for levothyroxine. Which statement made by the patient indicates that the education was effective?
- A. Avoid the use of iron supplements.
- B. Consume foods that are high in iodine.
- C. Take medication on an empty stomach.
- D. Administer levothyroxine at bedtime.
Correct Answer: C
Rationale: Levothyroxine should be taken on an empty stomach (C), 30-60 minutes before breakfast, for optimal absorption. Iron supplements (A) should be timed separately, not avoided. High-iodine foods (B) don’t enhance efficacy. Bedtime dosing (D) is less effective than morning.