Nokea
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.
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A client with OCD has a new prescription for Paroxetine. Which of the following instructions should the nurse include?
- A. It can take several weeks before you feel like the medication is helping.
- B. Take the medication just before bedtime to promote sleep.
- C. You should take the medication when needed for obsessive urges.
- D. Monitor for weight gain while taking this medication.
Correct Answer: A
Rationale: The correct answer is A. Paroxetine, an antidepressant commonly used for OCD, typically takes 1 to 4 weeks before the client experiences the full therapeutic benefit. Therefore, informing the client that it may take several weeks before feeling the medication's effects is crucial to manage expectations and ensure compliance with the treatment plan. Choice B is incorrect because Paroxetine is usually taken in the morning due to its activating effects and may cause insomnia if taken before bedtime. Choice C is incorrect because Paroxetine should be taken regularly as prescribed, not just when experiencing obsessive urges. Choice D is incorrect because although weight gain can be a side effect of Paroxetine, it is not a priority instruction compared to the delayed onset of therapeutic effects.
A client has a new prescription for Lisinopril. Which of the following laboratory values should be monitored?
- A. Serum potassium
- B. Serum sodium
- C. Serum calcium
- D. Serum magnesium
Correct Answer: A
Rationale: Corrected Rationale: Lisinopril is an ACE inhibitor that can cause hyperkalemia by reducing potassium excretion through the kidneys. Monitoring serum potassium levels is crucial to detect hyperkalemia early and prevent adverse effects such as cardiac arrhythmias. Choices B, C, and D are incorrect because Lisinopril is not known to significantly impact sodium, calcium, or magnesium levels in the same way it affects potassium levels.
A healthcare professional is preparing to administer an IV bolus of Morphine to a client for pain management. Which of the following assessments is the healthcare professional's priority?
- A. Respiratory rate
- B. Pain level
- C. Blood pressure
- D. Level of consciousness
Correct Answer: A
Rationale: The priority assessment for a client receiving an IV bolus of Morphine is the respiratory rate. Morphine can cause respiratory depression, which is a serious adverse effect. Monitoring the respiratory rate is crucial to detect any signs of respiratory compromise early and intervene promptly. Assessing pain level, blood pressure, and level of consciousness are also important but not the priority in this situation. Pain level can be assessed after ensuring the client's respiratory status is stable. Blood pressure and level of consciousness should be monitored but do not take precedence over the respiratory rate when administering Morphine.
A client is receiving treatment with methotrexate. Which of the following supplements should the nurse instruct the client to take?
- A. Folic acid
- B. Vitamin D
- C. Calcium
- D. Iron
Correct Answer: A
Rationale: The nurse should instruct the client to take folic acid when receiving treatment with methotrexate to reduce the risk of methotrexate toxicity. Methotrexate acts as a folic acid antagonist, leading to folic acid deficiency, which can be counteracted by supplementing with folic acid. Vitamin D, calcium, and iron are not specifically recommended to counteract methotrexate effects and do not play a significant role in mitigating methotrexate toxicity.
A provider prescribes phenobarbital for a client who has a seizure disorder. The medication has a long half-life of 4 days. How many times per day should the nurse expect to administer this medication?
- A. One
- B. Two
- C. Three
- D. Four
Correct Answer: A
Rationale: Phenobarbital has a long half-life of 4 days, meaning it remains at therapeutic levels in the body for an extended period. Due to this prolonged duration of action, the nurse should expect to administer phenobarbital once a day to maintain therapeutic levels and effectiveness. Administering it more than once a day would lead to unnecessary dosing and potential adverse effects as the medication remains active in the body for an extended period.