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A nurse is reinforcing teaching with a client who has a new prescription for lithium. Which of the following information should the nurse include in the teaching?
- A. Increase fluid intake
- B. Decrease sodium intake
- C. Eat foods high in potassium
- D. Take the medication 1 hr before meals.
Correct Answer: A
Rationale: The correct answer is A: Increase fluid intake. Lithium is a medication used to treat bipolar disorder, and it can cause dehydration and increase the risk of lithium toxicity. By increasing fluid intake, the client can maintain proper hydration levels, which helps to prevent lithium toxicity. This information is crucial for the client's safety and well-being.
Incorrect choices:
B: Decrease sodium intake - While monitoring sodium intake is important with lithium therapy, decreasing it is not necessary.
C: Eat foods high in potassium - While maintaining a balanced diet is important, focusing on potassium specifically is not directly related to lithium therapy.
D: Take the medication 1 hr before meals - Lithium can be taken with or without food, so the timing of meals in relation to medication is not a critical teaching point.
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A nurse is collecting data from a client before administering a hepatitis B immunization. The nurse should withhold the immunization if the client is allergic to which of the following substances?
- A. Baker's yeast
- B. Nuts
- C. Wheat
- D. Egg yolk
Correct Answer: A
Rationale: The correct answer is A: Baker's yeast. Hepatitis B vaccines are produced using baker's yeast, specifically Saccharomyces cerevisiae. If a client is allergic to baker's yeast, there is a risk of an allergic reaction to the vaccine. Nuts (B), wheat (C), and egg yolk (D) are not ingredients used in the hepatitis B vaccine production, so allergies to these substances would not necessitate withholding the immunization.
A nurse is caring for a client who has ulcerative colitis and is receiving sulfasalazine. Which of the following findings requires immediate intervention?
- A. Anorexia
- B. Arthralgia
- C. Nausea
- D. Wheezing
Correct Answer: D
Rationale: The correct answer is D: Wheezing. Wheezing is a sign of a severe allergic reaction to sulfasalazine, known as Stevens-Johnson syndrome, which is a medical emergency requiring immediate intervention to prevent respiratory distress and potential anaphylaxis. Anorexia, arthralgia, and nausea are common side effects of sulfasalazine but do not indicate an immediate threat to the client's well-being. Wheezing is the most critical finding that needs urgent attention.
A nurse is planning care for a client who has angina and a new prescription for nitroglycerin ointment. Which of the following actions should the nurse plan to take?
- A. Cover the administration area with plastic wrap.
- B. Massage the ointment into the skin.
- C. Spread the ointment in a 10 cm2 (4in2) area.
- D. Apply the ointment in a thick layer.
Correct Answer: A
Rationale: The correct answer is A. The nurse should cover the administration area with plastic wrap when applying nitroglycerin ointment to prevent accidental exposure to others and to ensure proper absorption of the medication. This step helps to enhance the drug's efficacy by promoting direct contact with the skin and preventing it from being rubbed off onto clothing or other surfaces. Massaging the ointment into the skin (B) may alter the absorption rate and distribution of the medication. Spreading the ointment in a 10 cm2 area (C) may lead to inaccurate dosing. Applying the ointment in a thick layer (D) may result in overdose or underdose due to inconsistent dosing.
A nurse in a provider's office is collecting data from a client who continues to have a migraine headache after taking sumatriptan orally 2 hr ago. Which of the following findings is the priority for the nurse to report?
- A. Tingling sensation
- B. Hypertension
- C. Dizziness
- D. Flushing
Correct Answer: B
Rationale: The correct answer is B: Hypertension. This is the priority finding for the nurse to report because sumatriptan, a medication used for migraines, can potentially cause a rare but serious side effect of increased blood pressure. Hypertension can lead to severe complications such as stroke or heart attack. Reporting hypertension promptly allows for timely intervention to prevent harm.
Other choices are less urgent:
A: Tingling sensation is a common side effect of sumatriptan and usually resolves on its own.
C: Dizziness may occur with sumatriptan but is not as concerning as hypertension.
D: Flushing is a common side effect and does not require immediate action like hypertension.
A nurse is preparing to administer medications to a client through an enteral feeding tube. Which of the following interventions is appropriate?
- A. Add the medications to the enteral feeding bag.
- B. Check for gastric residual 15 min after administering the medications
- C. Keep the client's head elevated 15° while administering the medications.
- D. Flush the tube with 30 ml of water between each medication
Correct Answer: D
Rationale: The correct answer is D: Flush the tube with 30 ml of water between each medication. Flushing the tube with water between medications helps prevent clogging and ensures proper medication administration. It also helps prevent interactions between different medications. Adding medications to the feeding bag (choice A) may cause drug interactions or alter the efficacy of the medications. Checking for gastric residual 15 min after administering medications (choice B) is not necessary for enteral tube medication administration. Keeping the client's head elevated 15° (choice C) is important during feeding, but not specifically for medication administration.