Nokea
A nurse is caring for a client who received 0.9% sodium chloride 1 L over 4 hr instead of over 8 hr as prescribeWhich of the following information should the nurse enter as a complete documentation of the incident?
- A. IV fluid infused over 4 hr instead of the prescribed 8 hr. Client tolerated fluids well, provider notified.
- B. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
- C. 1 L of 0.9% sodium chloride completed at 0900. Client denies shortness of breath.
- D. IV fluid initiated at 0500. Lungs clear to auscultation.
- E. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. This choice clearly states the key information - the type of IV fluid, volume, and duration of infusion.
2. Mentioning that vital signs were stable indicates client's safety was monitored.
3. Notifying the provider is crucial for any deviation from the prescribed treatment plan.
Incorrect Choices:
A. Fails to mention the type of IV fluid or client's vital signs, lacks detail.
C. Although it mentions the completion time, it does not address the deviation or client's tolerance.
D. Provides irrelevant information about the initiation time and lung assessment.
E. Similar to choice B, but lacks mentioning the infusion duration which is critical for documenting the incident.
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For which of the following client outcomes should the nurse administer chlordiazepoxide to a client experiencing acute alcohol withdrawal?
- A. Minimize diaphoresis
- B. Maintain abstinence
- C. Lessen craving
- D. Prevent delirium tremens
Correct Answer: D
Rationale: The correct answer is D: Prevent delirium tremens. Chlordiazepoxide is a benzodiazepine used to manage acute alcohol withdrawal symptoms, including preventing delirium tremens, a severe and potentially life-threatening complication. It helps to stabilize the client's central nervous system by reducing the risk of seizures and severe agitation associated with delirium tremens. Choices A, B, and C are incorrect as chlordiazepoxide's primary role in alcohol withdrawal is not to minimize diaphoresis, maintain abstinence, or lessen craving, but rather to manage the more serious symptoms of withdrawal like delirium tremens.
For which of the following adverse effects should the nurse monitor a client who is prescribed metoclopramide following bowel surgery?
- A. Muscle weakness
- B. Sedation
- C. Tinnitus
- D. Peripheral edema
Correct Answer: B
Rationale: The correct answer is B: Sedation. Metoclopramide is a medication that can cause sedation as a side effect. After bowel surgery, sedation can mask signs of postoperative complications such as abdominal pain or changes in vital signs. Muscle weakness (A), tinnitus (C), and peripheral edema (D) are not common adverse effects of metoclopramide and would not typically be monitored for in this situation. Sedation is the most relevant adverse effect to monitor for in a client post-bowel surgery, as it can impact the assessment and management of their recovery.
Which of the following findings is the best indication that morphine has been effective?
- A. The client's vital signs are within normal limits
- B. The client has not requested additional medication
- C. The client is sitting comfortably with eyes closed
- D. The client rates pain as 3 on a scale from 0 to 10
Correct Answer: D
Rationale: The correct answer is D because the client rating pain as 3 on a scale from 0 to 10 indicates that the morphine has effectively reduced their pain. This is a direct measure of the drug's efficacy. Choice A is not a specific indicator of pain relief. Choice B could mean the client is tolerating the pain, not necessarily that the medication is effective. Choice C is subjective and doesn't provide concrete evidence of pain relief.
Which of the following information should the nurse include in the teaching about medication reconciliation?
- A. The client's provider is required to complete medication reconciliation.
- B. Medication reconciliation at discharge is limited to the medications ordered at the time of discharge.
- C. A transition in care requires the nurse to conduct medication reconciliation.
- D. Medication reconciliation is limited to the names of the medications that the client is currently taking.
Correct Answer: C
Rationale: The correct answer is C: A transition in care requires the nurse to conduct medication reconciliation. This is because medication reconciliation is crucial during transitions of care to ensure safe and accurate medication management. The nurse plays a key role in reconciling medications to prevent errors and ensure continuity of care.
Incorrect choices:
A: The client's provider is required to complete medication reconciliation - Incorrect, as nurses are often responsible for medication reconciliation, not just the provider.
B: Medication reconciliation at discharge is limited to the medications ordered at the time of discharge - Incorrect, as reconciliation should encompass all medications the client is taking.
D: Medication reconciliation is limited to the names of the medications that the client is currently taking - Incorrect, as it should also include dosages, frequencies, and routes of administration.
For which of the following adverse effects should the nurse instruct the client taking acetazolamide for chronic open-angle glaucoma to monitor and report?
- A. Tingling of fingers
- B. Constipation
- C. Weight gain
- D. Oliguria
Correct Answer: A
Rationale: The correct answer is A: Tingling of fingers. Acetazolamide is a diuretic commonly used to treat glaucoma. Tingling of fingers is associated with electrolyte imbalances caused by the drug's diuretic effect. This symptom may indicate hypokalemia, a potential side effect of acetazolamide. Monitoring and reporting this symptom promptly can prevent serious complications.
Other choices are incorrect because:
B: Constipation is not a common side effect of acetazolamide.
C: Weight gain is unlikely as acetazolamide is a diuretic causing fluid loss.
D: Oliguria, decreased urine output, is not a usual side effect of acetazolamide.