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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.
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A nurse is caring for a client who reports muscle spasms after receiving haloperidol. Which of the following medications should the nurse expect to administer?
- A. Metoprolol
- B. Benztropine
- C. Oxycodone
- D. Risperidone
Correct Answer: B
Rationale: The correct answer is B: Benztropine. Benztropine is an anticholinergic medication commonly used to treat extrapyramidal symptoms such as muscle spasms caused by antipsychotic drugs like haloperidol. It works by blocking the action of acetylcholine in the brain, helping to alleviate muscle spasms. Metoprolol (A) is a beta-blocker used for hypertension, not muscle spasms. Oxycodone (C) is an opioid for pain relief, not muscle spasms. Risperidone (D) is another antipsychotic but not typically used to treat muscle spasms.
Vital Signs Day 1: Temperature 37.2° C (99° F), Blood pressure 124/56 mm Hg, Heart rate 66/min, Respiratory rate 16/min, Oxygen saturation 95% on room air; Day 2: Temperature 37.2° C (99° F), Heart rate 112/min, Respiratory rate 28/min, Blood pressure 148/86 mm Hg, Oxygen saturation 90% on room air; Medication Administration Record: Albuterol 2 inhalations every 4 to 6 hr PRN wheezing, Bisacodyl 10 mg suppository daily PRN constipation, Prochlorperazine 10 mg PO 3 to 4 times per day PRN nausea, Morphine 4 mg IV bolus every 4 hr PRN severe pain, Acetaminophen 325 to 650 mg every 4 to 6 hr PRN pain or temperature greater than 38.4° C (101.1° F); Nurses' Notes Day 1: Bilateral breath sounds are clear and present throughout. Client reports pain as 2 on a scale of 0 to 10. Abdomen soft, nondistended, bowel sounds hypoactive. Client has a history of asthma. Day 2: Respirations rapid and shallow. Bilateral breath sounds with scattered wheezing. Client reports pain as 8 on a scale of 0 to 10. Client reports no nausea or constipation. Abdomen soft, nondistended, bowel sounds audible.
The nurse should contribute to the plan of care by administering _______ and ______ to the client.
- A. Prochlorperazine
- B. Albuterol
- C. Morphine
- D. Bisacodyl
- E. Acetaminophen
Correct Answer: B, C
Rationale: The correct answer is B and C. Albuterol is a bronchodilator used to treat respiratory conditions like asthma, while morphine is an opioid analgesic for pain management. The nurse should administer these medications as part of the client's plan of care to address their specific health needs. Prochlorperazine (A) is an antiemetic for nausea and vomiting, not typically within a nurse's scope. Bisacodyl (D) is a laxative, Acetaminophen (E) is a pain reliever, and the remaining choices are not provided.
Vital Signs Day 1: Temperature 37.5° C (99.5° F), Heart rate 98/min, Respiratory rate 20/min, Blood pressure 180/86 mm Hg, Oxygen saturation 95% on room air, Weight 90 kg (198 lb); 2 months later: Temperature 37.5° C (99.5° F), Heart rate 48/min, Respiratory rate 20/min, Blood pressure 140/76 mm Hg, Oxygen saturation 97% on room air, Weight 91 kg (200 lb)
The nurse is evaluating the client's response to the medication. The client's ___________ and ____________ indicate the client's condition is improving.
- A. HDL Level
- B. Heart rate
- C. Potassium level
- D. Weight
- E. blood Pressure
Correct Answer: B, E
Rationale: The correct answer is B, Heart rate and E, Blood Pressure. Monitoring heart rate and blood pressure are vital signs that reflect the overall cardiovascular function and response to medication. An improvement in heart rate and blood pressure indicates better circulation and cardiac output, suggesting the client's condition is improving. The other choices (A, C, D) do not directly reflect the client's cardiovascular status and are not appropriate indicators of medication response. Weight (D) can fluctuate for various reasons, and HDL level (A) and Potassium level (C) are important but specific to different aspects of health. Thus, heart rate and blood pressure are the most relevant indicators in this context.
A nurse is reinforcing teaching with a client who has pancreatitis and a new prescription for pancrelipase. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take this medication whole.
- B. I can expect this medication to cure the pancreatitis.
- C. I should discontinue the medication if I develop fatty stools.
- D. I will take this medication at bedtime.
Correct Answer: A
Rationale: The correct answer is A: "I will take this medication whole." This is correct because pancrelipase should be taken whole to ensure the proper release of enzymes in the small intestine for digestion. Option B is incorrect because pancrelipase does not cure pancreatitis but helps with digestion. Option C is incorrect because fatty stools are expected side effects of pancrelipase and not a reason to discontinue the medication. Option D is incorrect because pancrelipase should be taken with meals or snacks, not specifically at bedtime.
A nurse is caring for a client who is postoperative. For which of the following findings should the nurse administer ondansetron?
- A. Client reports nausea.
- B. Client reports incisional pain.
- C. Client's respiratory rate is 14/min.
- D. Client's blood pressure is 110/72 mm Hg.
Correct Answer: A
Rationale: The correct answer is A. Ondansetron is commonly used to treat nausea and vomiting, especially in postoperative clients. Administering ondansetron for nausea can help alleviate the client's discomfort and prevent further complications. Choices B, C, and D do not indicate a need for ondansetron as they are not directly related to nausea. Choice B suggests a need for pain management, choice C indicates normal respiratory rate, and choice D shows a stable blood pressure. Therefore, administering ondansetron would not be appropriate for these findings.