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A nurse is collecting data from a client who is taking high doses of aspirin to treat rheumatoid arthritis. Which of the following findings indicates that the client has salicylism?
- A. Tinnitus
- B. Nuchal rigidity
- C. Pharyngitis
- D. Pruritus
Correct Answer: A
Rationale: The correct answer is A: Tinnitus. Salicylism is a toxic condition caused by high levels of salicylates, such as aspirin, in the body. Tinnitus is a common early sign of salicylism due to its ototoxic effects on the auditory nerve. Nuchal rigidity, pharyngitis, and pruritus are not typically associated with salicylism. Nuchal rigidity is more indicative of meningitis, pharyngitis suggests a throat infection, and pruritus is itching which is not specific to salicylism. Therefore, tinnitus is the most relevant finding in this context.
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A nurse is collecting data from a client who is taking sumatriptan. Which of the following reports indicates a therapeutic response to the medication?
- A. Increased bone mass
- B. Relief of chest pain
- C. Improved mood
- D. Absence of headache
Correct Answer: D
Rationale: The correct answer is D: Absence of headache. Sumatriptan is a medication used to treat migraines by constricting blood vessels in the brain. A therapeutic response to sumatriptan would be the absence of a headache, as the medication is intended to relieve migraine symptoms. Increased bone mass (A), relief of chest pain (B), and improved mood (C) are not expected therapeutic responses to sumatriptan. These symptoms are not typically associated with the mechanism of action or indications for sumatriptan use. Therefore, the absence of a headache is the most appropriate indicator of a therapeutic response to sumatriptan in this scenario.
A nurse is collecting data from a client who takes furosemide daily for heart failure. Which of the following laboratory values should the nurse review before administering the medication?
- A. Erythrocyte sedimentation rate
- B. Thyroxine
- C. Serum potassium
- D. Serum aspartate aminotransferase
Correct Answer: C
Rationale: The correct answer is C: Serum potassium. Furosemide is a loop diuretic that can cause potassium depletion, leading to hypokalemia. Monitoring serum potassium levels is crucial to prevent complications such as cardiac arrhythmias. Erythrocyte sedimentation rate (A) is not relevant for assessing furosemide therapy. Thyroxine (B) is a thyroid hormone and not directly affected by furosemide. Serum aspartate aminotransferase (D) is a liver enzyme and not specifically impacted by furosemide administration.
A nurse is talking with a client who has been taking levothyroxine to treat hypothyroidism. The nurse should instruct the client to avoid taking which of the following over-the-counter medications within 4 hr of taking levothyroxine?
- A. Fish oil supplements
- B. Bulk-forming laxatives
- C. Oral antihistamines
- D. Calcium supplements
Correct Answer: D
Rationale: The correct answer is D: Calcium supplements. Calcium can interfere with the absorption of levothyroxine, reducing its effectiveness. It is recommended to avoid taking calcium supplements within 4 hours of levothyroxine to ensure proper absorption. Fish oil supplements (A), bulk-forming laxatives (B), and oral antihistamines (C) do not typically interfere with levothyroxine absorption, so they are safe to take without waiting 4 hours.
A nurse is preparing to administer medication to a client who has a new prescription. Which of the following actions should the nurse take first?
- A. Identify the client using two means of identification.
- B. Document the time of the medication administration.
- C. Validate the prescription with the available medication.
- D. Calculate the correct amount of the medication.
Correct Answer: A
Rationale: The correct answer is A. Identifying the client using two means of identification is the first step to ensure the right patient receives the right medication. This process involves checking the client's name, date of birth, and/or unique identifier against the prescription and their identification band. Documenting the time of administration (B) is important but should come after verifying the patient's identity. Validating the prescription (C) and calculating the correct amount (D) are essential steps but should follow patient identification to prevent errors.
A nurse is caring for a client who had abdominal surgery. The client is grimacing and has a respiratory rate of 24/min. Which of the following actions should the nurse take first?
- A. Check the client's current level of pain.
- B. Play music in the client's room as a distraction.
- C. Assist the client to reposition in bed.
- D. Offer the client a cold compress.
Correct Answer: A
Rationale: The correct answer is A, checking the client's current level of pain. This is the priority because the client is grimacing, indicating discomfort. Assessing the pain level is crucial in determining the appropriate intervention. It helps in providing timely pain relief and ensuring the client's well-being. Choices B, C, and D are incorrect because they do not address the immediate need of assessing and managing the client's pain. Playing music, repositioning the client, or offering a cold compress may be helpful interventions, but they should come after evaluating the client's pain level.