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A nurse is caring for a six-year-old child who had surgery that morning. The child is awake and lying very still in bed. What should the nurse do?
- A. Use an “ouch†scale for pain assessment.
- B. Encourage the child to request pain medication when needed.
- C. Plan to administer pain medication if the child begins to cry.
- D. Ask the child to rate their pain on a scale of 1 to 10.
Correct Answer: A
Rationale: The correct answer is A: Use an "ouch" scale for pain assessment. This approach is appropriate for a six-year-old child as it uses a simple and understandable method to assess pain levels. The child may not verbalize pain or cry, so using a visual scale like an "ouch" scale can help the nurse accurately assess the child's pain level. Encouraging the child to request pain medication (B) assumes the child will always feel comfortable expressing their needs, which may not be the case. Planning to administer pain medication if the child cries (C) may lead to unnecessary medication administration if the child is not in pain. Asking the child to rate their pain on a scale of 1 to 10 (D) may be too complex for a young child to understand and communicate effectively.
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What is the responsibility of the nurse related to the patient's drug therapy? Select all that apply.
- A. Teaching the patient how to cope with therapy to ensure the best outcome.
- B. Altering the drug regime to optimize the outcome.
- C. Evaluating the effectiveness of therapy.
- D. Providing therapy as well as medications.
- E. Recommending over-the-counter medications to treat adverse effects of prescription drug therapy.
Correct Answer: A,C
Rationale: The correct answers are A and C. A nurse's responsibility related to a patient's drug therapy includes teaching the patient how to cope with therapy for optimal outcomes (A) and evaluating the effectiveness of the therapy (C). Teaching the patient ensures they understand how to take medications correctly and manage any side effects. Evaluating effectiveness allows for adjustments in the treatment plan if needed. Choices B, D, and E are incorrect. B - altering the drug regime should be done by the prescribing healthcare provider, not the nurse. D - providing therapy is beyond the scope of a nurse's responsibilities, as they focus on administering medications and supporting the patient. E - recommending over-the-counter medications falls under the purview of a pharmacist or physician, not a nurse.
The nurse is caring for a patient who is receiving a high dose of intravenous azithromycin to treat an infection. The patient is also taking acetaminophen for pain. The nurse should expect to review which lab value when monitoring for this drug side effect?
- A. Complete blood count.
- B. Urinalysis.
- C. Electrolytes.
- D. Liver enzymes.
Correct Answer: D
Rationale: The correct answer is D: Liver enzymes. Azithromycin can cause liver toxicity as a side effect. Monitoring liver enzymes such as AST and ALT levels is crucial to detect any signs of liver damage. Acetaminophen is also metabolized in the liver, so combining it with azithromycin may increase the risk of liver injury. Checking liver enzymes helps the nurse assess the patient's liver function and adjust the medication regimen if necessary.
A: Complete blood count is not typically affected by azithromycin or acetaminophen.
B: Urinalysis is not relevant for monitoring liver toxicity.
C: Electrolytes are important but not specifically related to the side effects of azithromycin or acetaminophen in this scenario.
What is the action of ergotamine?
- A. Increases hypoperfusion of basilar artery vascular bed.
- B. Decreases hypoperfusion of basilar artery vascular bed.
- C. Increases hyperperfusion of basilar artery vascular bed.
- D. Decreases hyperperfusion of basilar artery vascular bed.
Correct Answer: D
Rationale: The correct answer is D: Decreases hyperperfusion of basilar artery vascular bed. Ergotamine is a vasoconstrictor that acts on serotonin receptors, reducing blood flow and decreasing hyperperfusion in the basilar artery. This helps in treating conditions like migraines by reducing the dilation of blood vessels. Choice A is incorrect because ergotamine does not increase hypoperfusion, but rather decreases hyperperfusion. Choice B is incorrect as ergotamine does not decrease hypoperfusion. Choice C is incorrect since ergotamine does not increase hyperperfusion, rather it decreases it.
A geriatric patient received a narcotic analgesic before leaving the post-anesthesia care unit to return to the regular unit. What is the priority nursing action for the nurse receiving the patient on the regular unit?
- A. Administer a non-steroidal anti-inflammatory drug.
- B. Put side rails up and place bed in the lowest position.
- C. Encourage fluids.
- D. Create a restful dark environment.
Correct Answer: B
Rationale: The correct answer is B: Put side rails up and place bed in the lowest position. This is the priority nursing action as the geriatric patient who received a narcotic analgesic may experience drowsiness or confusion, increasing the risk of falls. By putting up the side rails and lowering the bed, the nurse is ensuring the patient's safety and preventing falls. Administering a non-steroidal anti-inflammatory drug (choice A) is not the priority as the patient's safety should be addressed first. Encouraging fluids (choice C) and creating a restful dark environment (choice D) are important but not as crucial as ensuring the patient's immediate safety.
What drug enhances the output of respiratory tract fluid by reducing the adhesiveness and surface tension of the fluid which facilitates the removal of viscous mucus?
- A. Guaifenesin.
- B. Dextromethorphan.
- C. Acetylcysteine.
- D. Flunisolide.
Correct Answer: A
Rationale: The correct answer is A: Guaifenesin. Guaifenesin is an expectorant that works by increasing respiratory tract fluid output, reducing adhesiveness and surface tension of the mucus. This helps in loosening and thinning the mucus, making it easier to clear from the airways. Dextromethorphan (B) is a cough suppressant, not an expectorant. Acetylcysteine (C) is a mucolytic that reduces mucus thickness but does not directly enhance fluid output. Flunisolide (D) is a corticosteroid used for inflammation, not mucus clearance.