Nokea
A nurse is reviewing the medical record of a client with major depressive disorder who is taking fluoxetine. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 80/min
- B. Blood pressure 130/80 mm Hg
- C. Weight gain of 2.2 kg (5 lb) in 1 week
- D. Temperature of 37.2°C (99°F)
Correct Answer: C
Rationale: The correct answer is C. A weight gain of 2.2 kg (5 lb) in 1 week can indicate fluid retention, a serious side effect of fluoxetine that should be reported to the provider. Choices A, B, and D are within normal ranges and are not alarming findings that would require immediate reporting to the provider. A heart rate of 80/min, blood pressure of 130/80 mm Hg, and a temperature of 37.2°C (99°F) are all within normal limits and not typically concerning in a client taking fluoxetine.
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A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?
- A. Position the client supine.
- B. Prepare an IV bolus of dextrose 5% in water.
- C. Administer methylergonovine IM.
- D. Administer calcium gluconate IV.
Correct Answer: D
Rationale: Administering calcium gluconate IV is the correct action when a client displays toxicity from magnesium sulfate. Calcium gluconate is used as the antidote for magnesium sulfate toxicity as it counteracts the effects. Positioning the client supine (Choice A) is not the immediate action needed. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Administering methylergonovine IM (Choice C) is used in postpartum hemorrhage, not for magnesium sulfate toxicity.
A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?
- A. Platelet count
- B. Potassium level
- C. Creatinine clearance
- D. Prealbumin
Correct Answer: A
Rationale: The correct answer is A: Platelet count. Platelet count helps assess clotting abnormalities that could cause petechiae and ecchymoses. Petechiae and ecchymoses are often associated with bleeding disorders, so it is crucial to evaluate the platelet count to determine if there is a deficiency in platelets. Choices B, C, and D are incorrect because potassium level, creatinine clearance, and prealbumin do not directly relate to assessing clotting abnormalities associated with petechiae and ecchymoses.
A client who has a new prescription for lithium is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I will avoid eating foods that contain tyramine.''
- B. ''I should increase my salt intake while taking this medication.''
- C. ''I should drink at least 2 liters of water each day while taking this medication.''
- D. ''I should avoid consuming caffeinated beverages while taking this medication.''
Correct Answer: C
Rationale: The correct answer is C. Drinking at least 2 liters of water daily is crucial for clients taking lithium to prevent dehydration and lithium toxicity. Lithium is a salt, so it's important for clients to maintain adequate hydration. Option A is incorrect because lithium does not interact with tyramine-containing foods. Option B is incorrect because increasing salt intake is not necessary and can actually exacerbate lithium toxicity. Option D is incorrect because avoiding caffeinated beverages is not a priority teaching point for clients taking lithium.
A client is taking sucralfate. Which of the following client statements indicates an understanding of the teaching?
- A. I should take this medication 1 hour before meals.
- B. I should take this medication 30 minutes after meals.
- C. I should take this medication only when I have symptoms of heartburn.
- D. I should take this medication with a glass of milk.
Correct Answer: A
Rationale: The correct answer is A. Sucralfate is most effective when taken 1 hour before meals to protect the stomach lining. Option B is incorrect because sucralfate should not be taken after meals. Option C is incorrect because sucralfate is typically taken on a regular schedule, not just when symptoms occur. Option D is incorrect because sucralfate should not be taken with milk, as it can interfere with its effectiveness.
A nurse is providing discharge teaching to a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?
- A. Take the medication with food to reduce stomach upset.
- B. Store the medication in a cool, dry place.
- C. Take one tablet every 5 minutes until the pain is relieved, up to three doses.
- D. This medication may cause drowsiness.
Correct Answer: C
Rationale: The correct answer is to instruct the client to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is essential for managing angina attacks effectively. Choice A is incorrect because nitroglycerin sublingual tablets should be placed under the tongue for rapid absorption, not taken with food. Choice B is incorrect because nitroglycerin tablets should be stored in their original container at room temperature, away from moisture and heat. Choice D is incorrect because nitroglycerin typically does not cause drowsiness as a side effect.