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A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first?
- A. Assist the client into a standing position
- B. Check the blood pressure with the client in a supine position
- C. Determine the client's blood pressure 1 min after each position change
- D. Place the client in a sitting position
Correct Answer: B
Rationale: The correct answer is B: Check the blood pressure with the client in a supine position. This is the first action the nurse should take because it establishes the baseline blood pressure of the client in a resting position. Orthostatic hypotension is characterized by a drop in blood pressure upon standing. By measuring the blood pressure in a supine position first, the nurse can accurately assess the extent of the blood pressure change when the client stands up.
Choices A, C, and D are incorrect because they involve positioning changes before establishing the baseline blood pressure. It is crucial to first determine the baseline blood pressure to accurately diagnose orthostatic hypotension. Choice A (Assist the client into a standing position) and D (Place the client in a sitting position) may exacerbate the client's symptoms if orthostatic hypotension is present. Choice C (Determine the client's blood pressure 1 min after each position change) is premature without knowing the baseline blood pressure.
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A nurse is teaching a class about reducing the risk of medication errors. Which of the following information should the nurse include?
- A. Provide a dedicated area for the nurse to prepare medications
- B. Wait to document medications given to clients until the end of a shift
- C. Remove medications from automatic dispensing systems before they are reviewed by pharmacists
- D. Prepare medications for multiple clients at the same time
Correct Answer: A
Rationale: Correct Answer: A - Provide a dedicated area for the nurse to prepare medications.
Rationale: Providing a dedicated area for medication preparation helps reduce distractions and promotes focus, decreasing the likelihood of errors. This setup allows for organization and prevents cross-contamination. It also encourages proper storage and disposal of medications, fostering a safer environment for medication preparation.
Summary of Other Choices:
B: Waiting to document medications until the end of a shift can lead to errors in documentation and potential confusion. Real-time documentation is crucial for accuracy.
C: Removing medications from automatic dispensing systems before pharmacist review bypasses a critical safety check, increasing the risk of errors.
D: Preparing medications for multiple clients simultaneously can lead to mix-ups and errors, as it increases the chances of confusion and incorrect dosing.
A nurse is teaching a client who has a new prescription for zolpidem. The nurse should instruct the client that which of the following is an adverse effect of zolpidem?
- A. Memory loss
- B. Dry mouth
- C. Hypertension
- D. Urinary retention
Correct Answer: A
Rationale: The correct answer is A: Memory loss. Zolpidem is a sedative-hypnotic medication commonly used for insomnia. One of its adverse effects is memory loss, particularly short-term memory impairment. Zolpidem works by enhancing the effects of GABA, which can lead to memory issues. Dry mouth (B) is a common side effect of many medications but not typically associated with zolpidem. Hypertension (C) and urinary retention (D) are not common adverse effects of zolpidem. It is important to educate the client about memory loss as a potential side effect to ensure they are aware and can report any concerning symptoms to their healthcare provider.
A nurse is teaching a class about pharmacodynamics. The nurse should include that which of the following medication levels occurs when a medication is at the lowest serum concentration?
- A. Trough
- B. Peak
- C. Half-life
- D. Toxic
Correct Answer: A
Rationale: The correct answer is A: Trough. The trough level represents the lowest serum concentration of a medication in the body, usually measured just before the next dose is administered. This is important in monitoring the effectiveness and safety of the drug. Peak levels (B) indicate the highest concentration. Half-life (C) refers to the time it takes for half of the drug to be eliminated from the body. Toxic levels (D) are when the drug concentration is too high and can lead to harmful effects. Other choices are not relevant to the lowest serum concentration.
A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?
- A. The client demonstrated proper technique when drawing up 8 units of insulin
- B. The client stated ‘I struggle to see those little lines on the syringe’
- C. The client FBS was 95 mg/dL
- D. The client seems to be more comfortable performing self-administration of insulin
Correct Answer: D
Rationale: The correct answer is D. The charge nurse should recommend revising this entry because it implies the client is self-administering insulin, which is beyond the scope of practice for a client. This could lead to serious harm if not addressed.
A, B, and C are incorrect because they all indicate proper client care and documentation. A shows proper technique, B indicates client's concern with syringe lines, and C provides the client's fasting blood sugar level.
A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.8
Rationale: The correct answer is 0.8 mL. To determine this, divide the desired dose (30 mg) by the concentration (40 mg/mL) to get 0.75. Since we need to round to the nearest tenth, 0.75 rounds up to 0.8 mL. The other choices are incorrect because: A: 0.7 mL, B: 0.9 mL, C: 0.6 mL, D: 1.0 mL, E: 0.5 mL, F: 1.2 mL, G: 0.3 mL. These choices do not accurately reflect the calculated dose based on the given information.