Nokea
A nurse is assessing a client who has hypermagnesemia. Which of the following medications should the nurse prepare to administer?
- A. Protamine sulfate
- B. Acetylcysteine
- C. Calcium gluconate
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Calcium gluconate. In hypermagnesemia, there is an excess of magnesium in the blood, leading to muscle weakness, cardiac arrhythmias, and respiratory depression. Calcium gluconate is the antidote for hypermagnesemia as it works by antagonizing the effects of magnesium. By administering calcium gluconate, the nurse can help reverse the symptoms associated with hypermagnesemia and restore normal calcium levels in the body. Protamine sulfate (Choice A) is used to reverse the effects of heparin, acetylcysteine (Choice B) is used as an antidote for acetaminophen overdose, and flumazenil (Choice D) is used to reverse the effects of benzodiazepines. These medications are not indicated for hypermagnesemia.
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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 discussing adverse reactions to pain medications in older adult clients with a newly licensed nurse. Which of the following findings should the nurse include as risk factors for an adverse drug reaction? (SATA)
- A. Polypharmacy
- B. Increased rate of absorption
- C. Decreased percentage of body fat
- D. Multiple health problems
Correct Answer: A,C,D,E
Rationale: To determine risk factors for adverse drug reactions in older adults, consider the following:
A: Polypharmacy increases the likelihood of drug interactions and adverse effects.
C: Decreased body fat can affect drug distribution, leading to higher drug concentrations.
D: Multiple health problems may require multiple medications, increasing the risk of adverse reactions.
E: Age-related changes in liver and kidney function can affect drug metabolism and excretion.
Other choices are incorrect because increased rate of absorption does not necessarily increase risk and choices F and G were not provided.
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion.
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
- D. Obtain the first unit of packed RBCs from the blood bank.
- E. Start an IV bolus of lactated Ringer's solution.
Correct Answer: B
Rationale: [0, 1, 0, 0]
The correct answer is Stay with the client for the first 15 min of the transfusion. This action is indicated to monitor for adverse reactions such as fever, chills, or signs of hemolysis. Documenting the blood product transfusion (A) is important but not a priority during the initial phase. Titrating the infusion rate (C) and obtaining the blood product (D) are essential, but staying with the client for monitoring takes precedence. Starting an IV bolus (E) is not related to blood transfusion monitoring.
A nurse is assessing a client who is taking an osmotic laxative. Which of the following findings should the nurse identify as an indication of fluid volume deficit?
- A. Nausea
- B. Weight gain
- C. Headache
- D. Oliguria
Correct Answer: D
Rationale: The correct answer is D: Oliguria. Osmotic laxatives, such as lactulose or polyethylene glycol, work by drawing water into the colon to soften the stool. If a client on osmotic laxatives is experiencing oliguria (decreased urine output), it can be a sign of fluid volume deficit due to the body trying to conserve water. Nausea (A) is a common side effect of osmotic laxatives but not a specific indicator of fluid volume deficit. Weight gain (B) is not associated with fluid volume deficit. Headache (C) can be caused by various factors and is not a specific sign of fluid volume deficit.
A nurse is reviewing the laboratory data of a client prior to administering IV tobramycin. Which of the following laboratory values should the nurse report to the provider?
- A. Sodium 137 mEq/L
- B. Hct 4.3%
- C. Hgb 15 g/dL
- D. Creatinine 2.5 mg/dL
Correct Answer: D
Rationale: The correct answer is D: Creatinine 2.5 mg/dL. Elevated creatinine levels indicate potential kidney dysfunction, which is crucial when administering nephrotoxic medications like tobramycin to prevent further kidney damage. Elevated creatinine levels can lead to drug accumulation, increasing the risk of toxicity.
Choice A (Sodium 137 mEq/L) is within normal range and not directly related to tobramycin administration. Choices B (Hct 4.3%) and C (Hgb 15 g/dL) are related to red blood cell levels and not specifically relevant to tobramycin administration. Therefore, they do not need immediate reporting.