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A nurse is assessing a client 1 hr after administering morphine for pain. The nurse should identify which of the following findings as the best indication that the morphine has been effective?
- A. The client's vital signs are within normal limits.
- B. The client has not requested additional medication.
- C. The client is resting comfortably with eyes closed.
- D. The client rates pain as 3 on a scale from 0 to 10.
Correct Answer: D
Rationale: Correct Answer: D. The client rates pain as 3 on a scale from 0 to 10.
Rationale: Pain assessment is subjective. The client's self-report of pain is the most reliable indicator of pain relief efficacy. A pain rating of 3 indicates that the pain has decreased from the initial level, suggesting that the morphine has been effective in managing the pain.
Summary of Other Choices:
A: The client's vital signs being within normal limits may not directly correlate with pain relief. Vital signs can be influenced by various factors other than pain relief.
B: The client not requesting additional medication does not necessarily indicate effective pain management as some individuals may hesitate to ask for more medication.
C: The client resting comfortably with eyes closed may indicate relaxation but does not specifically confirm pain relief.
E, F, G: No additional choices provided.
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Which of the following medications interacts with carbamazepine?
- A. Nicotine transdermal system
- B. Diphenhydramine
- C. Estrogen-progestin combination (Non-hormonal forms of contraception)
- D. Beclomethasone
Correct Answer: C
Rationale: The correct answer is C: Estrogen-progestin combination (Non-hormonal forms of contraception). Carbamazepine induces the metabolism of estrogen-based contraceptives, leading to decreased efficacy and potential contraceptive failure. This interaction can result in unintended pregnancies. Choices A, B, and D do not have significant interactions with carbamazepine.
Which of the following interventions should the nurse include in the plan of care for a client who has hypertension and is to start taking metoprolol?
- A. Weigh the client weekly
- B. Determine apical pulse prior to administering
- C. Administer the medication 30 minutes before breakfast
- D. Monitor the client for jaundice
Correct Answer: B
Rationale: The correct answer is B: Determine apical pulse prior to administering. Metoprolol is a beta-blocker that can lower heart rate. By assessing the apical pulse before administering, the nurse can ensure the heart rate is within the safe range for medication administration. Weighing the client weekly (A) is not directly related to metoprolol therapy. Administering the medication 30 minutes before breakfast (C) is not specific timing for metoprolol. Monitoring for jaundice (D) is not a common side effect of metoprolol.
Which of the following adverse effects should the nurse include in the teaching for a client who is to begin taking tamoxifen for the treatment of breast cancer?
- A. Urinary retention
- B. Constipation
- C. Bradycardia
- D. Hot flashes
Correct Answer: D
Rationale: The correct answer is D: Hot flashes. Tamoxifen is known to cause hot flashes as a common side effect due to its estrogen-blocking properties. This is important to include in teaching as it can affect the client's quality of life. Urinary retention (A), constipation (B), and bradycardia (C) are not commonly associated with tamoxifen use. Hot flashes are a well-documented side effect, making it the most appropriate choice for client education.
A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift and the client received atenolol instead of allopurinol.Which of the following actions should the nurse take first when discovering a medication error in which atenolol was given instead of allopurinol to a client with gout?
- A. Obtain the client's blood pressure
- B. Contact the client's provider
- C. Inform the charge nurse
- D. Complete an incident report
Correct Answer: A
Rationale: The correct action for the nurse to take first in this situation is to obtain the client's blood pressure (Choice A). This is important because atenolol is a beta-blocker that can lower blood pressure, and giving it to a client with gout instead of allopurinol can potentially result in adverse effects or exacerbate the underlying condition. By obtaining the client's blood pressure, the nurse can assess if there have been any significant changes since the administration of the incorrect medication. This immediate assessment allows the nurse to monitor for any potential adverse effects and take appropriate action if necessary. Contacting the client's provider (Choice B) would be important, but assessing the immediate impact on the client's health by checking the blood pressure takes precedence. Informing the charge nurse (Choice C) and completing an incident report (Choice D) are important steps to take after addressing the immediate health concern of the client.
A nurse is teaching a client about the prescribed medication. Which of the following statements should the nurse include when teaching the client about the prescribed medication? Select all that apply.
- A. The medication can cause nausea
- B. so take with a meal.
- C. You can experience vivid nightmares.
- D. You may notice your urine becomes lighter in color.
- E. Consumption of a high-protein meal can reduce the effectiveness of the medication.
- F. You may initially notice an increase in involuntary movements.
- G. This medication can make you light-headed if you stand up too quickly from a seated or lying position.
Correct Answer: A, B, E,F
Rationale: The correct statements to include when teaching the client about the prescribed medication are A, B, E, and F. Statement A is important to mention as it informs the client about a potential side effect (nausea) of the medication. Statement B is crucial as taking the medication with a meal can help reduce the likelihood of nausea occurring. Statement E is relevant because high-protein meals can indeed interfere with the medication's effectiveness, so the client should be aware of this. Statement F is crucial as it prepares the client for a possible side effect of an increase in involuntary movements. These statements are important for the client to understand to ensure safe and effective medication use. Statements C, D, and G are incorrect as they do not pertain to the medication's side effects, interactions, or administration, making them irrelevant in this context.