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A nurse is caring for a patient who has a new prescription for atorvastatin. Which of the following instructions should the nurse include? What instructions should the nurse include for atorvastatin?
- A. Take the medication in the morning.
- B. Report muscle pain or weakness.
- C. Avoid foods high in vitamin K.
- D. Take the medication with grapefruit juice.
Correct Answer: B
Rationale: The correct answer is B: Report muscle pain or weakness. This is crucial because atorvastatin, a statin medication, can cause muscle-related side effects like myopathy or rhabdomyolysis. By instructing the patient to report muscle pain or weakness, the nurse can monitor for these serious adverse effects and take appropriate actions if needed.
A: Taking the medication in the morning is not specific to atorvastatin and can be taken at any time.
C: Avoiding foods high in vitamin K is not relevant to atorvastatin, as it does not interact with vitamin K.
D: Taking the medication with grapefruit juice is not recommended with atorvastatin as grapefruit juice can interact with certain medications, but not specifically with atorvastatin.
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A nurse is conducting a patient's history and physical examination. Which information should the nurse consider as subjective data? Which information is subjective data?
- A. Petechiae
- B. Nausea
- C. Cyanosis
- D. Fever
Correct Answer: B
Rationale: Subjective data is information provided by the patient based on their feelings, perceptions, or beliefs. Nausea falls under this category as it is a symptom that the patient experiences and reports subjectively. Petechiae, cyanosis, and fever are objective data as they can be observed or measured directly. Petechiae are small red or purple spots on the skin, cyanosis is a bluish discoloration of the skin due to lack of oxygen, and fever is an elevated body temperature, all of which can be confirmed through visual inspection or measurement. Therefore, choice B, nausea, is the correct answer as it relies on the patient's subjective experience.
A nurse is performing tracheostomy care for a patient and plans to remove copious secretions. What actions should the nurse take? What action should the nurse take for tracheostomy suctioning?
- A. Lubricate the suction catheter tip with sterile saline
- B. Hyperventilate the patient on 100% oxygen prior to suctioning
- C. Perform chest physiotherapy prior to suctioning
- D. Suction two to three times with a 60-second pause between passes
Correct Answer: D
Rationale: The correct answer is D: Suction two to three times with a 60-second pause between passes. This is the correct action for tracheostomy suctioning to prevent hypoxia and tissue damage. Suctioning should be limited to 10-15 seconds to minimize the risk of hypoxia. Pausing between passes allows the patient to recover oxygen saturation levels. Choice A is incorrect because lubricating the suction catheter tip with sterile saline is not necessary for tracheostomy suctioning. Choice B is incorrect as hyperventilating the patient on 100% oxygen prior to suctioning can lead to respiratory alkalosis. Choice C is incorrect as performing chest physiotherapy prior to suctioning is not indicated in tracheostomy care.
A patient with a history of migraines is at the clinic complaining of a throbbing headache. Which of the following questions should the nurse include in the assessment? Which question should the nurse ask for migraine assessment?
- A. Have you experienced any nausea or vomiting with your headache?
- B. Are the lights in this room bothering you?
- C. Have you noticed any confusion or clouded thinking?
- D. Did you feel weak before the headache started or do you feel weak now?
Correct Answer: A
Rationale: The correct answer is A: "Have you experienced any nausea or vomiting with your headache?" This question is crucial in assessing migraines as nausea and vomiting are common accompanying symptoms. Nausea and vomiting are associated with activation of the autonomic nervous system during migraines. The other options are not as directly related to migraines. B is more relevant to light sensitivity in migraines, C is more related to confusion or cognitive symptoms, and D is more focused on weakness, which are not typically primary symptoms of migraines.
A nurse in a coronary care unit is admitting a patient who has had CPR following a cardiac arrest. The patient is receiving lidocaine IV at 2 mg/min. When the patient asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions? Why is the patient receiving lidocaine?
- A. Relieves pain.
- B. Slows intestinal motility.
- C. Dissolves blood clots.
- D. Prevents dysrhythmias.
Correct Answer: D
Rationale: The patient is receiving lidocaine to prevent dysrhythmias after experiencing a cardiac arrest. Lidocaine is a class IB antiarrhythmic drug that stabilizes the cardiac cell membrane, reducing the likelihood of abnormal electrical activity and dysrhythmias. It does not relieve pain, slow intestinal motility, or dissolve blood clots. Therefore, the correct answer is D, as it directly addresses the purpose of administering lidocaine in this specific clinical scenario.
A nurse is caring for a patient who is receiving a blood transfusion. The patient reports chills and back pain 15 minutes after the transfusion begins. Which of the following actions should the nurse take first? What should the nurse do first for transfusion reaction symptoms?
- A. Slow the transfusion rate.
- B. Stop the transfusion.
- C. Administer acetaminophen.
- D. Notify the provider.
Correct Answer: B
Rationale: The correct answer is B: Stop the transfusion. When a patient develops symptoms of a transfusion reaction such as chills and back pain, it is crucial to stop the transfusion immediately to prevent further complications. This action takes priority over other options as it ensures patient safety. Slowing the transfusion rate (choice A) may not be sufficient to address the reaction promptly. Administering acetaminophen (choice C) may help alleviate symptoms but does not address the underlying cause. Notifying the provider (choice D) is important but should come after stopping the transfusion to address the immediate issue.