Nokea
A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?
- A. Instruct the client's visitors not to operate the PCA pump.'
- B. Check the client's pain level every 8 hours.'
- C. Diarrhea is an adverse effect of morphine PCA.'
- D. Using morphine PCA increases the client's risk of toxicity.'
Correct Answer: A
Rationale: The correct answer is A, instruct the client's visitors not to operate the PCA pump. This is important to prevent unauthorized administration of medication by individuals who are not trained to use the PCA pump, ensuring patient safety. Checking the client's pain level every 8 hours (B) is important but not the priority in monitoring PCA. Diarrhea is not a common adverse effect of morphine PCA (C), and using morphine PCA does not inherently increase the client's risk of toxicity (D) if used appropriately.
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A nurse is reviewing the medication record of a client who has hypertension. Which of the following medications should the nurse administer to lower the client's blood pressure?
- A. Promethazine
- B. Amlodipine
- C. Fluconazole
- D. Phenazopyridine
Correct Answer: B
Rationale: The correct answer is B: Amlodipine. Amlodipine is a calcium channel blocker commonly used to treat hypertension by relaxing blood vessels, reducing blood pressure. It is a first-line medication for hypertension management. Promethazine (A) is an antihistamine, Fluconazole (C) is an antifungal, and Phenazopyridine (D) is a urinary analgesic, none of which are indicated for hypertension. Selecting Amlodipine aligns with evidence-based practice guidelines for hypertension management.
A nurse is reinforcing teaching with a client who has a new prescription for alendronate for the treatment of osteoporosis. The nurse should instruct the client to monitor for which of the following adverse effects?
- A. Anorexia
- B. Jaw pain
- C. Insomnia
- D. Bruising
Correct Answer: B
Rationale: The correct answer is B: Jaw pain. Alendronate, a bisphosphonate medication used to treat osteoporosis, can cause a rare but serious side effect called osteonecrosis of the jaw (ONJ), characterized by jaw pain, swelling, and possible infection. It is essential for the nurse to instruct the client to monitor for any signs of jaw pain to promptly report to their healthcare provider. Anorexia (A), insomnia (C), and bruising (D) are not typically associated with alendronate use for osteoporosis and would not be common adverse effects that the client needs to monitor for.
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.
Nurses' Notes
Medication Reconciliation
Medicine Prescriptions
1 week ago:
Client who was diagnosed with asthma during childhood presents to the clinic with increased night-time coughing and shortness of breath during activities of daily living. The client reports increased use of their rescue inhaler. The client has a non-productive cough and inspiratory and expiratory wheezing heard during auscultation. Client prescribed prednisone and requested to follow up in 5 to 7 days.
Today:
The client reports their asthma symptoms have improved since beginning the prednisone. Lung sounds clear with occasional wheezing. The client has gained 1.36 kg (3 lb) since the last visit. The client states they received the "flu shot" 3 days ago to avoid getting sick. The client states they hurt their back while moving the couch 5 days ago and have been taking ibuprofen twice daily since then.
Complete the following sentence by using the lists of options: The client is most at risk for developing ___ due to their ___.
- A. Cushing syndrome
- B. influenza
- C. peptic ulcers
- D. NSAID use
- E. recent immunization
- F. weight gain
Correct Answer: C,D
Rationale:
The correct answer is C,D because the client is at risk for developing peptic ulcers due to NSAID use. NSAIDs can cause irritation and damage to the stomach lining, leading to peptic ulcers. The other options, such as Cushing syndrome (A), influenza (B), recent immunization (E), and weight gain (F), are not directly related to the client's risk of developing peptic ulcers due to NSAID use.
A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device. Which of the following actions by the nurse requires intervention by the charge nurse?
- A. The nurse monitors the client for oversedation
- B. The nurse reassures the client that the PCA device will not cause an overdose
- C. The nurse asks the client to demonstrate dose delivery.
- D. The nurse administers a PCA dose for the client.
Correct Answer: D
Rationale: Correct Answer: D. The nurse administering a PCA dose for the client requires intervention. This is because only the client should be allowed to self-administer medication via a PCA device to ensure safety and prevent medication errors. Allowing the nurse to administer the dose goes against the principles of PCA therapy, which empowers the client to manage their pain relief within safe limits.
Choice A: Monitoring the client for oversedation is a standard nursing practice and does not require intervention.
Choice B: Reassuring the client about the PCA device is important for patient education but does not require immediate intervention.
Choice C: Asking the client to demonstrate dose delivery is a proactive approach to ensure the client understands how to use the device correctly and does not require intervention unless the client is unable to demonstrate understanding.