Nokea
A nurse is caring for a client who is receiving an oral solution of codeine to suppress a nonproductive cough. Which of the following is the nurse's data collection priority following administration of this medication?
- A. Heart rate
- B. Respiratory rate
- C. Blood pressure
- D. Level of consciousness
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate. Codeine is a central nervous system depressant that can cause respiratory depression as a side effect. Therefore, monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress or suppression. This should be the nurse's priority to ensure the client's safety.
A: Heart rate may be affected by codeine, but respiratory rate is a more direct indicator of respiratory depression.
C: Blood pressure is not typically affected by codeine in the context of suppressing a cough.
D: Level of consciousness is important, but respiratory rate takes precedence as it directly reflects potential respiratory depression.
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Vital Signs
Laboratory Results
0800:
Client is admitted with a 3-day history of abdominal cramps and diarrhea of 4 to 5 liquid stools per day.
Client was taking amoxicillin/clavulanate 875 mg PO every 12 hr for 10 days for a respiratory tract infection. Antibiotics completed 7 days ago.
Bilateral breath sounds clear and present throughout.
Abdomen soft, distended with hyperactive bowel sounds audible in all 4 quadrants.
Stool is watery and contains mucous. Stool sent for culture.
The nurse should first address the client's ___ followed by the client's ___. (Options: Hgb level, Blood pressure, temperature, Hct level, abdominal findings, potassium level)
- A. Hgb level
- B. Blood pressure
- C. temperature
- D. Hct level
- E. abdominal findings
- F. potassium level
Correct Answer: B,F
Rationale: Action to Take: B, F; Potential Condition: Hypovolemia; Parameter to Monitor: Blood Pressure, Potassium Level.
Rationale:
1. Blood pressure should be addressed first to assess perfusion status and hemodynamic stability.
2. Potassium level should be monitored next due to potential electrolyte imbalances in hypovolemia.
3. Hgb, Hct, and abdominal findings are important but secondary to addressing perfusion and electrolyte balance.
4. Temperature is not typically the initial concern in hypovolemia.
A nurse is caring for a client receiving gentamicin. For which of the following should the nurse monitor the client?
- A. Tinnitus
- B. Tachycardia
- C. Polyuria
- D. Photophobia
Correct Answer: A
Rationale: The correct answer is A: Tinnitus. The nurse should monitor the client for tinnitus because gentamicin can cause ototoxicity, leading to hearing loss and tinnitus. Tachycardia (B), polyuria (C), and photophobia (D) are not commonly associated with gentamicin use. Tachycardia may be a sign of other issues, polyuria could indicate kidney problems, and photophobia is sensitivity to light, which is not a typical side effect of gentamicin. Therefore, the nurse should focus on monitoring for tinnitus as a potential adverse effect of gentamicin therapy.
A nurse is preparing to administer regular and NPH insulin to a client. Which of the following actions should the nurse take?
- A. Withdraw the NPH insulin last.
- B. Mix the medications in a 3-mL syringe.
- C. Administer the medications in two separate syringes.
- D. Inject air into the regular vial first.
Correct Answer: A
Rationale: The correct answer is A: Withdraw the NPH insulin last. This is because regular insulin is a clear solution and should be withdrawn first to prevent contamination with the cloudy NPH insulin. Mixing the medications in a 3-mL syringe (B) is not recommended as it may alter the effectiveness of the insulin. Administering the medications in two separate syringes (C) is important to avoid mixing them prior to administration. Injecting air into the regular vial first (D) is unnecessary and not a standard practice.
A nurse is reviewing the medical record of a client who has a new prescription for celecoxib to treat osteoarthritis. Which of the following should the nurse recognize as a contraindication for this medication?
- A. Concurrent use of chondroitin
- B. Concurrent use of calcium supplements
- C. Penicillin allergy
- D. Sulfonamide allergy
Correct Answer: D
Rationale: The correct answer is D: Sulfonamide allergy. Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that belongs to the sulfonamide class of medications. Patients with a known allergy to sulfonamides are at an increased risk of developing an allergic reaction to celecoxib. It is important for the nurse to recognize this contraindication to prevent potential serious adverse reactions such as anaphylaxis.
A: Concurrent use of chondroitin - This is not a contraindication for celecoxib as there is no known significant interaction between chondroitin and celecoxib.
B: Concurrent use of calcium supplements - Calcium supplements do not interact with celecoxib and are not a contraindication for its use.
C: Penicillin allergy - Penicillin allergy is not related to celecoxib use as they are different classes of medications with distinct mechanisms of action.
In summary, the correct answer is D because
A nurse is evaluating the laboratory results of four clients. The nurse should report which of the following laboratory results to the provider?
- A. A client who has a prescription for heparin and an aPTT of 90 seconds (30-40 seconds).
- B. A client who has a prescription for warfarin and an INR of 2.0 (0.8 to 1.1).
- C. A client who has a prescription for heparin and an aPTT of 65 seconds (30-40 seconds).
- D. A client who has a prescription for warfarin and an INR of 3.0 (0.8 to 1.1).
Correct Answer: A
Rationale: The correct answer is A. A client who has a prescription for heparin and an aPTT of 90 seconds (30-40 seconds) should be reported to the provider because the aPTT result is significantly above the therapeutic range, indicating a potential risk of bleeding due to excessive anticoagulation. Heparin therapy requires close monitoring of aPTT levels to ensure the medication's efficacy and safety. Reporting this result promptly to the provider allows for timely adjustment of the heparin dosage to prevent complications.
Choices B, C, and D are incorrect because they fall within or close to the desired therapeutic ranges for the respective medications. Therefore, they do not require immediate reporting to the provider as they suggest appropriate anticoagulation levels.