Nokea
A nurse accidentally administers the medication metformin instead of metoprolol to a client. Which of the following actions should the nurse take?
- A. Monitor the client's thyroid function levels.
- B. Collect the client's uric acid level.
- C. Obtain the client's HDL level.
- D. Check the client's glucose level.
Correct Answer: D
Rationale: The correct answer is D: Check the client's glucose level. Metformin is a medication used to treat diabetes, so administering it instead of metoprolol could lead to hypoglycemia. Checking the client's glucose level will help determine if the client is experiencing low blood sugar levels due to the medication error. Monitoring thyroid function (A), collecting uric acid levels (B), and obtaining HDL levels (C) are not relevant in this situation and would not address the immediate concern of potential hypoglycemia.
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A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissue surrounding the insertion site. Which of the following actions should the nurse take?
- A. Flush the IV catheter
- B. Apply pressure to the IV site
- C. Elevate the extremity
- D. Slow the infusion rate
Correct Answer: C
Rationale: The correct action is to elevate the extremity. Elevating the extremity above the level of the heart helps to reduce swelling and prevent further fluid infiltration into the surrounding tissue. This promotes proper circulation and limits potential complications. Flushing the IV catheter (choice A) would not address the infiltration issue. Applying pressure to the IV site (choice B) could cause further damage to the tissue. Slowing the infusion rate (choice D) may not be sufficient to prevent further infiltration.
A nurse manager is planning an in-service about pain management with opioids for clients who have cancer. Which of the following information should the nurse manager include?
- A. IM administration is recommended if PO opioids are ineffective
- B. Respiratory depression decreases as opioid tolerance develops
- C. Meperidine is the opioid of choice for treating chronic pain
- D. Withhold PRN pain medication for the client who is receiving opioids every 6 hr
Correct Answer: B
Rationale: The correct answer is B because respiratory depression decreases as opioid tolerance develops. Opioid tolerance occurs with prolonged use, leading to a decrease in the side effect of respiratory depression. This information is crucial for healthcare providers managing cancer pain with opioids. Choice A is incorrect because oral administration is preferred over intramuscular for better absorption and convenience. Choice C is incorrect as meperidine is not recommended for chronic pain due to its toxic metabolite. Choice D is incorrect as PRN pain medication should not be withheld for clients on scheduled opioid doses to ensure adequate pain control.
A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the following statements should the nurse include in the teaching?
- A. Diarrhea is a common adverse effect of this medication.
- B. Ringing in the ears is an expected adverse effect of this medication.
- C. Notify your provider if you develop a fever while taking this medication.
- D. You might experience weight loss while taking this medication.
Correct Answer: C
Rationale: The correct answer is C: Notify your provider if you develop a fever while taking this medication. This is important because clozapine can cause a serious condition called agranulocytosis, which can lead to a fever. The nurse should emphasize the significance of monitoring for fever and promptly notifying the healthcare provider. Choice A is incorrect because diarrhea is not a common adverse effect of clozapine. Choice B is incorrect as ringing in the ears is not an expected adverse effect. Choice D is incorrect because weight gain, not weight loss, is a common side effect of clozapine.
A client who has active tuberculosis and is taking rifampin reports that his urine and sweat have developed a red tinge. Which of the following actions should the nurse take?
- A. Check the client's liver function test results.
- B. Instruct the client to increase his fluid intake.
- C. Document this as an expected finding.
- D. Prepare the client for dialysis.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Document this as an expected finding. Rifampin is known to cause harmless discoloration of bodily fluids like urine and sweat. This is a common side effect and does not indicate any serious issues. The nurse should document this finding to track the client's response to the medication and educate the client about it.
Summary of Incorrect Choices:
A: Checking liver function test results is not necessary for the red discoloration caused by rifampin.
B: Increasing fluid intake will not resolve the red tinge as it is a known side effect of rifampin.
D: Dialysis is not indicated for the harmless discoloration caused by rifampin.
A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
- A. Ibuprofen
- B. Naproxen sodium
- C. Acetaminophen
- D. Aspirin
Correct Answer: C
Rationale: Rationale: Acetaminophen is the correct choice because it does not have an antiplatelet effect like aspirin, ibuprofen, and naproxen sodium. Enoxaparin is an anticoagulant that works by preventing blood clots, so it is safer to take acetaminophen for pain relief as it does not increase the risk of bleeding. Aspirin, ibuprofen, and naproxen sodium can increase the risk of bleeding when taken with enoxaparin due to their antiplatelet effects. Therefore, acetaminophen is the safest option for pain relief while on enoxaparin therapy.