Nokea
A nurse is administering the first dose of ramipril to a client who has hypertension. The client reports feeling dizzy and lightheaded. Which of the following should the nurse administer?
- A. 15 g of carbohydrates
- B. Naloxone
- C. Diphenhydramine
- D. Fluid bolus
Correct Answer: D
Rationale: The correct answer is D: Fluid bolus. The client is experiencing symptoms of hypotension, a common side effect of ramipril. Administering a fluid bolus helps increase blood volume, improving blood pressure and alleviating dizziness and lightheadedness. It is important to address the underlying cause of the symptoms. Choices A, B, and C are not appropriate in this situation as they do not address the hypotension caused by ramipril. Administering carbohydrates (A) is irrelevant, naloxone (B) is used for opioid overdose, and diphenhydramine (C) is an antihistamine and not indicated for hypotension.
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A nurse is collecting data from a client who has been taking methimazole for 2 months for the treatment of a thyroid imbalance. Which of the following findings indicates that the medication is effective?
- A. Weight gain
- B. Decreased menstrual flow
- C. Clear breath sounds
- D. Increased libido
Correct Answer: A
Rationale: The correct answer is A: Weight gain. Methimazole is used to treat hyperthyroidism, which often causes weight loss due to increased metabolism. If the medication is effective, the client's thyroid hormone levels should normalize, leading to a potential reversal of weight loss and even weight gain. Decreased menstrual flow (B) and increased libido (D) are not direct indicators of methimazole effectiveness. Clear breath sounds (C) could indicate improved respiratory status but are not specific to thyroid function.
A nurse is preparing to administer 0800 medications to a client. The medication administration record (MAR) states 'phenobarbital' and the medication the pharmacy supplied is pentobarbital. Which of the following actions should the nurse take?
- A. Check the client's MAR to see what the client received the day before
- B. Ask the client what medication she took yesterday.
- C. Ask the client if she has any allergies.
- D. Check the prescription in the client's medical record.
Correct Answer: D
Rationale: The correct answer is D: Check the prescription in the client's medical record. This is the appropriate action for the nurse to take because it ensures that the medication being administered matches the prescription ordered by the healthcare provider. By verifying the prescription in the client's medical record, the nurse can confirm if pentobarbital is indeed the correct medication prescribed for the client. Checking the MAR alone may not provide the necessary information about the prescribed medication. Asking the client about previous medications or allergies (choices A, B, C) may not be reliable sources of information regarding the specific prescription. Therefore, option D is the most appropriate and logical course of action in this situation.
Nurses' Notes
0800:
Client reports frequent cough, wheezing, and tightness of chest. Bilateral breath sounds with scattered inspiratory and expiratory wheezes.
1000:
Reinforced teaching about newly prescribed medications.
Click to highlight the instructions the nurse should reinforce to the client.
- A. Take your albuterol when you are having difficulty breathing.
- B. Hold your breath for 20 seconds when taking your albuterol.
- C. Take the salmeterol 5 minutes before the albuterol when you need both medications.
- D. Take the salmeterol 2 times each day.
- E. Rinse out your mouth after taking the fluticasone.
- F. Take the fluticasone as needed for an asthma attack.
Correct Answer: A,D,E
Rationale: Sure, here is a detailed explanation for each choice:
A: Taking albuterol during difficulty breathing helps relieve symptoms promptly.
D: Salmeterol should be taken twice daily for optimal effectiveness.
E: Rinsing mouth after fluticasone reduces the risk of oral thrush.
Incorrect choices:
B: Holding breath doesn't affect albuterol efficacy.
C: Timing salmeterol before albuterol isn't necessary.
F: Fluticasone is a controller, not a rescue inhaler.
A nurse is reinforcing teaching with a client who has a prescription for nystatin oral suspension. Which of the following instructions should the nurse include in the teaching?
- A. Swish the medication in your mouth.
- B. Use a straw when taking this medication.
- C. Take the medication with meals.
- D. Drink at least 8 ounces of water after taking the medication.
Correct Answer: A
Rationale: The correct answer is A: Swish the medication in your mouth. Nystatin oral suspension is an antifungal medication used to treat oral thrush, a fungal infection in the mouth. By swishing the medication in the mouth before swallowing, it allows the medication to come into contact with the affected areas in the mouth, ensuring better efficacy. Using a straw (choice B) may not be effective as it may not reach all areas of the mouth. Taking the medication with meals (choice C) may interfere with the absorption of the medication. Drinking water after taking the medication (choice D) is not necessary for its effectiveness.
A nurse is caring for a client who has been taking epoetin alfa for 3 months. Which of the following laboratory tests should the nurse monitor to determine the effectiveness of the medication?
- A. Troponin
- B. Thyroxine (T4)
- C. Aspartate aminotransferase (AST)
- D. Hgb
Correct Answer: D
Rationale: The correct answer is D: Hgb (hemoglobin). Epoetin alfa is a medication used to stimulate red blood cell production. Monitoring hemoglobin levels is crucial to assess the effectiveness of the medication in increasing red blood cell count. Hemoglobin reflects the oxygen-carrying capacity of red blood cells, indicating if the medication is addressing the underlying anemia. Troponin (A) is used to assess heart muscle damage, not relevant in this case. Thyroxine (B) reflects thyroid function, not related to epoetin alfa therapy. Aspartate aminotransferase (AST) (C) is a liver enzyme, not relevant for monitoring this medication's efficacy.