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A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement
for 4 days. Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg per rectum
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: The correct answer is A: Bisacodyl 10 mg per rectum. Bisacodyl is a stimulant laxative that helps stimulate bowel movements. Given the client's situation of not having a bowel movement for 4 days postpartum with a third-degree perineal laceration, prompt relief is needed to prevent complications such as constipation or increased pressure on the perineal area. Administering Bisacodyl per rectum will provide a faster onset of action compared to oral medications, ensuring timely relief for the client.
Choice B: Magnesium hydroxide is a laxative used for constipation but may not provide immediate relief for the client in this urgent situation.
Choice C: Famotidine is a histamine-2 blocker used for managing stomach acid but is not indicated for addressing constipation.
Choice D: Loperamide is an antidiarrheal medication and is contraindicated in this scenario as it can worsen constipation.
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A nurse is teaching a guardian of a school-age child who has a new prescription for a fluticasone metered-dose inhaler. Which of the following information should the nurse include in the teaching? (SATA)
- A. Soak the inhaler in water after use.
- B. Have your child take one inhalation as needed for shortness of breath.
- C. Shake the device prior to administration.
- D. A spacer will make it easier to use the device.
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: Shake the device prior to administration - Shaking the inhaler ensures proper mixing of the medication for effective delivery to the lungs.
D: A spacer will make it easier to use the device - A spacer helps improve medication delivery by ensuring more of the medication reaches the lungs rather than the mouth or throat.
E: - Additional information may include the importance of proper inhaler technique, how to clean the device, how to monitor for side effects, and when to seek medical help.
Incorrect Choices:
A: Soak the inhaler in water after use - Soaking the inhaler in water can damage the device and affect the medication's effectiveness.
B: Have your child take one inhalation as needed for shortness of breath - The prescription likely specifies a specific dosing regimen that should be followed, rather than using the inhaler as needed.
A nurse is planning teaching for a client who is trying to quit smoking. Which of the following instructions about nicotine replacement options should the nurse include?
- A. Change the nicotine patch every other day.
- B. Do not drink beverages while sucking on a nicotine lozenge.
- C. Chew nicotine gum for 10 min before spitting it out.
- D. Administer 2 sprays of nicotine nasal spray in each nostril with each dose.
Correct Answer: B
Rationale: The correct answer is B: Do not drink beverages while sucking on a nicotine lozenge. This instruction is important because beverages can interfere with the absorption of nicotine from the lozenge. Nicotine replacement therapy works best when the nicotine is absorbed properly, so avoiding beverages while using the lozenge will help ensure its effectiveness. Changing the nicotine patch every other day (choice A) is incorrect as patches are typically changed daily. Chewing nicotine gum for 10 minutes before spitting it out (choice C) is incorrect as the gum should be chewed until a tingling sensation is felt, then parked between the cheek and gum. Administering 2 sprays of nicotine nasal spray in each nostril with each dose (choice D) is incorrect as the dosage is usually one spray in each nostril.
A nurse is reviewing a client's 0800 laboratory values at 1100. The nurse notes that the client received heparin at 1000. Which of the following laboratory values warrants an incident report?
- A. ePTT 90 seconds
- B. Hgb 16 g/dL
- C. INR 1.6
- D. WBC 6,000/mm3
Correct Answer: A
Rationale: The correct answer is A: ePTT 90 seconds. This value indicates a higher than normal clotting time, which could potentially lead to bleeding complications due to excessive anticoagulation from heparin. The other values (B, C, D) are within normal ranges and do not indicate an immediate risk or adverse outcome related to heparin administration. An incident report is necessary to document and address the elevated ePTT to ensure appropriate interventions are taken to prevent harm to the patient.
A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following as an indication of an allergic reaction following the injection?
- A. Urticaria
- B. Bradycardia
- C. Pallor
- D. Dyspepsia
Correct Answer: A
Rationale: The correct answer is A: Urticaria. Urticaria, or hives, is a classic sign of an allergic reaction. It presents as raised, red, itchy welts on the skin. This occurs due to histamine release in response to the allergen (penicillin in this case). Monitoring for urticaria is crucial as it indicates a potentially serious allergic reaction that may progress to anaphylaxis. Bradycardia (B), Pallor (C), and Dyspepsia (D) are not typically associated with allergic reactions to penicillin. Bradycardia is a slow heart rate, pallor is paleness of the skin, and dyspepsia is indigestion. These symptoms are more likely related to other conditions or side effects rather than an allergic reaction.
A nurse is reviewing the laboratory results of a client who is taking amitriptyline. Which of the following laboratory values should the nurse report to the provider?
- A. Total bilirubin 1.5 mg/dL
- B. Potassium 4.2 mEq/L
- C. Hct 0.44%
- D. WBC count 5
Correct Answer: A
Rationale: The correct answer is A. Total bilirubin levels should be reported because amitriptyline can cause hepatotoxicity. Elevated bilirubin could indicate liver damage. Option B, potassium level, is not typically affected by amitriptyline. Option C, hematocrit, and option D, WBC count, are not directly related to amitriptyline use. Options E, F, and G are not provided. In summary, the nurse should report elevated total bilirubin levels due to potential hepatotoxicity from amitriptyline.