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A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 lb.) since the last visit 2 days ago. Which of the following actions should the nurse take first?
- A. Encourage the client to dangle the legs while sitting in a chair
- B. Teach the client about foods low in sodium
- C. Determine medication adherence by the client
- D. Notify the provider of the client's weight gain
Correct Answer: D
Rationale: The correct answer is D: Notify the provider of the client's weight gain. This is the first action the nurse should take because sudden weight gain in a client with heart failure could indicate fluid retention, which may worsen the client's condition. By notifying the provider, the nurse can ensure timely intervention to adjust the medication or treatment plan. Encouraging leg dangling (A) may help with circulation but does not address the immediate concern of weight gain. Teaching about low-sodium foods (B) is important for long-term management but not the priority at this moment. Determining medication adherence (C) is important but should come after addressing the immediate weight gain issue.
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A nurse is instructing a client who has a new prescription for a daily dose of lovastatin extended-release. Which of the following information should the nurse include in the teaching?
- A. You will need liver function tests before beginning therapy.
- B. Avoid consuming dairy products while taking this medication.
- C. You may crush the medication and mix it with applesauce.
- D. You should take the medication in the morning.
Correct Answer: A
Rationale: The correct answer is A: You will need liver function tests before beginning therapy. This is important because lovastatin, a statin medication, can potentially cause liver damage. Liver function tests are necessary to monitor for any signs of liver toxicity. Choice B is incorrect because there is no specific interaction between lovastatin and dairy products. Choice C is incorrect as lovastatin extended-release should not be crushed as it may affect its effectiveness. Choice D is incorrect as there is no specific time of the day required to take lovastatin.
A nurse is reviewing the laboratory values of a client who is taking atorvastatin. Which of the following laboratory values indicates the treatment has been effective?
- A. BUN 15 mg/dL
- B. Blood glucose 90 mg/dL
- C. Urine specific gravity 1.020
- D. LDL 120 mg/dL
Correct Answer: D
Rationale: The correct answer is D: LDL 120 mg/dL. Atorvastatin is a medication used to lower LDL cholesterol levels. A decrease in LDL levels indicates the effectiveness of the treatment in reducing the risk of cardiovascular events. BUN, blood glucose, and urine specific gravity are not directly related to the effectiveness of atorvastatin in lowering cholesterol levels. BUN reflects kidney function, blood glucose monitors glucose levels, and urine specific gravity indicates hydration status. Therefore, D is the best indicator of treatment effectiveness.
A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol, characterized by symptoms similar to Parkinson's disease. A shuffling gait, which is a slow, dragging walk with short steps and reduced arm swing, is a classic manifestation. Serpentine limb movement (A) is not associated with pseudoparkinsonism. Nonreactive pupils (C) are not a typical symptom of pseudoparkinsonism. Smacking lips (D) is a sign of tardive dyskinesia, another side effect of antipsychotic medications.
A nurse is planning to administer medication to an older adult client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Tilt the client's head back when administering the medications
- B. Mix the medications with a semisolid food for the client
- C. Administer more than one pill to the client at a time
- D. Place the medications on the back of the client's tongue
Correct Answer: B
Rationale: The correct answer is B: Mix the medications with a semisolid food for the client. This is the safest option for a client with dysphagia as it reduces the risk of choking or aspiration. Mixing medications with food can help make swallowing easier and safer for the client. Tilt the client's head back (A) can increase the risk of choking. Administering more than one pill at a time (C) can lead to swallowing difficulties. Placing medications on the back of the tongue (D) can trigger a gag reflex in clients with dysphagia.
A nurse is caring for a client who is to receive potassium replacement. The provider's prescription reads, 'Potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 min.' Which of the following reasons should the nurse clarify this prescription with the provider?
- A. Potassium chloride should be diluted in dextrose 5% in water.
- B. The potassium infusion rate is too rapid.
- C. Another formulation of potassium should be given IV.
- D. The client should be treated by giving potassium by IV bolus.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Potassium chloride infusion rate should not exceed 10 mEq/hr to prevent hyperkalemia and cardiac arrhythmias.
2. In this case, 30 mEq in 100 mL over 30 min exceeds the safe rate.
3. Clarification is needed to adjust the infusion rate to avoid potential harm.
4. Other choices are incorrect as dextrose dilution, different formulations, and IV bolus are not the primary concerns.