Nokea
A nurse suspects that a client is developing salicylism. Which of the following would help confirm this suspicion?
- A. Tinnitus
- B. Bradycardia
- C. Sweating
- D. Impaired vision
- E. Mental confusion
Correct Answer: A,C,E
Rationale: Signs of salicylism include tinnitus, sweating, mental confusion, dizziness, impaired hearing, nausea, vomiting, flushing, rapid breathing, tachycardia, diarrhea, lassitude, drowsiness, respiratory depression, and coma.
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A nurse is administering a nonopioid analgesic to a client. Which of the following should the nurse perform during the ongoing assessment?
- A. Reassess client's pain rating 30 to 60 minutes after drug administration.
- B. Assess joints for greater mobility.
- C. Check vital signs every 4 hours.
- D. Document pain severity, location, and intensity if pain persists.
- E. Assess the joints for decreased inflammation
Correct Answer: A,B,C,D,E
Rationale: Ongoing assessment includes monitoring pain relief, reassessing pain every 30 to 60 minutes, documenting pain characteristics, checking vital signs every 4 hours, and assessing joints for reduced inflammation and improved mobility.
A nurse is caring for a patient who is receiving a salicylate for pain relief. The nurse would assess the client for which of the following suggesting salicylism?
- A. Constipation
- B. Bradycardia
- C. Sleeplessness
- D. Flushing
Correct Answer: D
Rationale: Flushing is a symptom of salicylism. Tachycardia, not sleepliness or constipation, is associated with salicylism.
Which of the following are important points for the nurse to cover when performing discharge teaching for a client receiving a salicylate?
- A. Inform all health care providers of salicylate use.
- B. Discard salicylates if they smell like vinegar.
- C. Take salicylates with food.
- D. Store salicylates in the bathroom.
- E. Keep salicylate container closed tightly.
Correct Answer: A,B,C,E
Rationale: Discharge teaching includes taking salicylates with food, informing providers of use, discarding salicylates with a vinegar smell, and storing in a tightly closed container away from humidity, not in the bathroom.
A patient has taken a 15-gram (15,000-mg) dose of acetaminophen and is brought by her parents to the emergency department. As the dosage is relatively high, there is a chance of acute acetaminophen poisoning. Which of the following assessment findings would indicate acute acetaminophen toxicity?
- A. Hypotension
- B. High fever
- C. Sweating
- D. Rapid, deep breathing
Correct Answer: A
Rationale: Hypotension is a sign of acute acetaminophen toxicity. High fever, sweating, and rapid, deep breathing are not typically associated with it.
A patient who has been prescribed aspirin wants to know more about willow bark as a substitute for aspirin. Which of the following would the nurse integrate into the response as an advantage of willow bark as compared to aspirin?
- A. Willow bark is ideal for patients with peptic ulcers.
- B. Willow bark works relatively quickly as compared to aspirin.
- C. Small amounts of willow bark produce a noticeable effect.
- D. Willow bark has fewer adverse reactions than other salicylates.
Correct Answer: D
Rationale: Willow bark has fewer adverse reactions than other salicylates but is not ideal for peptic ulcer patients, takes longer to work, and requires larger amounts for effect.