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A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissue surrounding the insertion site. Which of the following actions should the nurse take?
- A. Flush the IV catheter
- B. Apply pressure to the IV site
- C. Elevate the extremity
- D. Slow the infusion rate
Correct Answer: C
Rationale: The correct action is to elevate the extremity. Elevating the extremity above the level of the heart helps to reduce swelling and prevent further fluid infiltration into the surrounding tissue. This promotes proper circulation and limits potential complications. Flushing the IV catheter (choice A) would not address the infiltration issue. Applying pressure to the IV site (choice B) could cause further damage to the tissue. Slowing the infusion rate (choice D) may not be sufficient to prevent further infiltration.
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A nurse is caring for a client in a provider's office. 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, so take with a meal
- B. You can experience vivid nightmares."
- C. You may notice your urine becomes lighter in color
- D. Consumption of a high protein meal can reduce the effectiveness of the medication
- E. You may initially notice an increase in involuntary movements
- F. 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: Correct Answer: A, B, E, F
Rationale:
A: Taking the medication with a meal can help reduce nausea, enhancing tolerance.
B: Mentioning vivid nightmares prepares the client for a potential side effect.
E: Increase in involuntary movements is a common side effect of certain medications.
F: Informing about potential dizziness upon standing up quickly promotes safety.
These statements address medication effects and side effects, promoting client understanding and safety.
Incorrect Choices:
C: Urine color change may not be relevant to the medication being discussed.
D: High protein meal interaction is not mentioned for this medication.
Incorrect choices lack relevance or do not address potential medication effects, making them not suitable for client education.
A nurse is caring for a client who has a new diagnosis of benign prostate hypertrophy and a prescription for doxazosin. The client tells the nurse, 'I do not take this medication. I would prefer a natural therapy.' Which of the following supplements should the nurse suggest the client discuss with the provider?
- A. Black cohosh
- B. Garlic
- C. Feverfew
- D. Saw palmetto
Correct Answer: D
Rationale: The correct answer is D: Saw palmetto. Saw palmetto is commonly used as a natural remedy for benign prostate hypertrophy due to its potential benefits in reducing symptoms. It works by decreasing inflammation and promoting the shrinkage of the prostate gland. The nurse should suggest discussing saw palmetto with the provider as it aligns with the client's preference for natural therapy.
Choice A: Black cohosh is not typically used for prostate issues but rather for menopausal symptoms in women.
Choice B: Garlic is not specifically indicated for benign prostate hypertrophy and is more commonly known for its cardiovascular benefits.
Choice C: Feverfew is primarily used for migraine headaches and has no direct association with prostate health.
In summary, saw palmetto is the most appropriate supplement to suggest as it targets the client's condition effectively compared to the other options provided.
A nurse is preparing to administer 4,000 units of heparin subcutaneously to a client who has deep-vein thrombosis. Available is heparin 10,000 units/mL. How many mL of heparin should the nurse administer? (Round to the nearest tenth.)
Correct Answer: 0.4
Rationale: To calculate the mL of heparin to administer, use the formula: desired dose (4,000 units) ÷ concentration (10,000 units/mL) = X mL. 4,000 ÷ 10,000 = 0.4 mL. The correct answer is 0.4 mL because it accurately represents the calculated dose needed for the client. Other choices are incorrect as they do not align with the correct calculation.
A nurse is reviewing the list of current medications for a client who is to start a prescription for carbamazepine. The nurse should identify that which of the following medications interacts with carbamazepine?
- A. Nicotine transdermal system
- B. Diphenhydramine
- C. Estrogen-progestin combination
- D. Beclomethasone
Correct Answer: C
Rationale: The correct answer is C: Estrogen-progestin combination. Carbamazepine can decrease the effectiveness of estrogen-containing medications, including estrogen-progestin combinations, by increasing their metabolism. This can lead to reduced contraceptive efficacy and breakthrough bleeding.
Nicotine transdermal system (choice A) does not have a significant interaction with carbamazepine. Diphenhydramine (choice B) is an antihistamine and does not interact with carbamazepine. Beclomethasone (choice D) is a corticosteroid and does not have a significant interaction with carbamazepine.
A nurse is caring for a client who is taking digoxin to treat heart failure. Which of the following predisposes this client to developing digoxin toxicity?
- A. Taking a high ceiling diuretic
- B. Having a 10-year history of COPD
- C. Having a prolapsed mitral valve
- D. Taking an HMG CoA reductase inhibitor
Correct Answer: A
Rationale: The correct answer is A: Taking a high ceiling diuretic. High ceiling diuretics, such as furosemide, can lead to hypokalemia, which increases the risk of digoxin toxicity. Digoxin competes with potassium for binding sites on the Na+/K+-ATPase pump in the heart, so low potassium levels can lead to an increased concentration of digoxin in the body, predisposing the client to toxicity. Choices B, C, and D are incorrect as they do not directly impact digoxin levels or toxicity. A history of COPD (B) or a prolapsed mitral valve (C) do not specifically predispose a client to digoxin toxicity. Taking an HMG CoA reductase inhibitor (D) does not interact directly with digoxin.