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A nurse administers a dose of metformin to a client instead of the prescribed dose of metoclopramidWhich of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Notify the provider.
- C. Check the client's blood glucose.
- D. Fill out an incident report.
Correct Answer: C
Rationale: The correct answer is C: Check the client's blood glucose. This is the first action the nurse should take because metformin is used to treat diabetes and can lower blood sugar levels. Checking the client's blood glucose will help assess if the client is experiencing hypoglycemia due to the medication error. Reporting the incident to the charge nurse (A) and filling out an incident report (D) are important steps, but assessing the client's immediate condition takes priority. Notifying the provider (B) can be done after ensuring the client's safety. The other options are not relevant to addressing the immediate concern of potential hypoglycemia.
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Which of the following findings should indicate to the nurse that the ondansetron has been effective?
- A. Client reports a decrease in pain
- B. Client reports a decrease in nausea
- C. Client reports a decrease in coughing
- D. Client reports a decrease in diarrhea
Correct Answer: B
Rationale: The correct answer is B: Client reports a decrease in nausea. Ondansetron is commonly prescribed to treat nausea and vomiting. A decrease in nausea indicates the medication's effectiveness in managing this specific symptom. Choices A, C, and D are incorrect because ondansetron does not directly target pain, coughing, or diarrhea. It is important for the nurse to focus on the primary purpose of the medication and assess the related symptoms to determine its effectiveness.
Which of the following information should the nurse include in the teaching for a school-age child with a new prescription for a fluticasone metered-dose inhaler? (Select all that apply)
- A. Soak the inhaler in water after use
- B. Have your child take one inhalation as needed for shortness of breath
- C. Shake the device prior to administration
- D. A spacer will make it easier to use the device
- E. Rinse your child's mouth following administration
Correct Answer: E
Rationale: The correct answer is E: Rinse your child's mouth following administration. Fluticasone is a corticosteroid inhaler that can cause oral thrush as a side effect. Rinsing the mouth after each use helps prevent this side effect. Choice A is incorrect because soaking the inhaler in water can damage the device. Choice B is incorrect because fluticasone is a maintenance medication, not a rescue inhaler for shortness of breath. Choice C is incorrect because shaking the device is not necessary for a metered-dose inhaler. Choice D is incorrect because while a spacer can help improve inhaler technique, it is not essential for using a metered-dose inhaler.
Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism in a client taking haloperidol?
- 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 resembling Parkinson's disease. A shuffling gait, where the client takes small steps with feet barely leaving the floor, is a classic manifestation. Serpentine limb movement (A) is not typically associated with pseudoparkinsonism. Nonreactive pupils (C) can be a sign of anticholinergic toxicity, not pseudoparkinsonism. Smacking lips (D) is more indicative of tardive dyskinesia, another side effect of antipsychotics.
Which of the following medications for pain relief can be taken concurrently with enoxaparin?
- A. Ibuprofen
- B. Naproxen sodium
- C. Acetaminophen
- D. Aspirin
Correct Answer: C
Rationale: Correct Answer: C (Acetaminophen)
Rationale:
1. Acetaminophen is a non-steroidal anti-inflammatory drug (NSAID) that does not affect platelet function.
2. Enoxaparin is an anticoagulant that works by inhibiting blood clot formation.
3. Taking acetaminophen with enoxaparin does not increase the risk of bleeding.
4. Choices A, B, and D (Ibuprofen, Naproxen sodium, Aspirin) are NSAIDs that can increase the risk of bleeding when taken with enoxaparin.
A nurse is preparing to administer PO sodium polystyrene sulfonate to a client who has hyperkalemiWhich of the following actions should the nurse plan to take?
- A. Hold the client's other oral medications for 1 hour post-administration.
- B. Inform the client that this medication can turn stool a light tan color.
- C. Keep the client's solution in the refrigerator for up to 72 hours.
- D. Monitor the client for constipation.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client for constipation. Sodium polystyrene sulfonate is a medication used to treat hyperkalemia by binding excess potassium in the intestines for elimination. Constipation is a common side effect, as the medication can cause a decrease in bowel motility. The nurse should monitor the client for signs of constipation, such as abdominal discomfort, decreased frequency of bowel movements, or difficulty passing stools. This is essential to prevent complications such as bowel obstruction. Holding the client's other oral medications, informing about stool color changes, or refrigerating the solution are not relevant actions for administering sodium polystyrene sulfonate.