A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?
- A. Remove all objects that contain latex from the client’s room.
- B. Verify the client’s medication prescriptions do not include cephalosporin.
- C. Notify dietary services to adjust the client’s diet.
- D. Have the client purchase a medication alert bracelet to wear in the hospital.
Correct Answer: B
Rationale: The correct answer is B: Verify the client’s medication prescriptions do not include cephalosporin. This is essential because cephalosporins are antibiotics that share a similar structure to penicillin and can potentially cause an allergic reaction in individuals with a penicillin allergy. By ensuring that the client's medication prescriptions do not include cephalosporin, the nurse is taking a proactive step to prevent any adverse reactions.
Removing objects containing latex (choice A) is not directly related to the client’s penicillin allergy. Notifying dietary services to adjust the client’s diet (choice C) is unnecessary as the allergy is to penicillin, not food. Having the client purchase a medication alert bracelet (choice D) is not as immediate or essential as verifying medication prescriptions.
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A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles?
- A. Veracity
- B. Fidelity
- C. Nonmaleficence
- D. Autonomy
Correct Answer: C
Rationale: The correct answer is C: Nonmaleficence. This principle of ethics requires healthcare providers to do no harm to their patients. In this scenario, discontinuing the experimental chemotherapy medication after evidence of rapidly advancing kidney failure demonstrates the nurse's commitment to preventing further harm to the client. By stopping the medication that is causing harm, the nurse is upholding the principle of nonmaleficence.
Other choices are incorrect:
A: Veracity - Veracity pertains to truthfulness and honesty in communication with patients. Discontinuing the medication is not related to truthfulness.
B: Fidelity - Fidelity refers to the obligation to fulfill commitments and promises made to patients. Discontinuing the medication is not about fulfilling commitments.
D: Autonomy - Autonomy is the right of patients to make their own decisions about their healthcare. Discontinuing the medication is not about respecting the patient's autonomy in this context.
A nurse is providing discharge teaching to a client who has a new prescription for verapamil for angina. Which of the following instructions should the nurse include?
- A. You can expect swelling of the ankles while taking this medication.
- B. Do not take this medication on an empty stomach.
- C. Limit your fluid intake to meal times.
- D. Increase your daily intake of dietary fiber.
Correct Answer: D
Rationale: The correct answer is D: Increase your daily intake of dietary fiber. Verapamil, a calcium channel blocker used for angina, can cause constipation as a side effect. Increasing dietary fiber helps prevent constipation by promoting bowel regularity. This instruction is important for the client's overall well-being and medication compliance.
A: Swelling of the ankles is not a common side effect of verapamil.
B: Verapamil can be taken with or without food, so taking it on an empty stomach is not necessary.
C: There is no need to limit fluid intake to meal times while taking verapamil.
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
- A. Exophthalmos
- B. Photophobia
- C. Lethargy
- D. Weight loss
Correct Answer: C
Rationale: Rationale: Hypothyroidism is characterized by decreased thyroid hormone levels, leading to symptoms such as lethargy due to slowed metabolism. Exophthalmos (bulging eyes) is associated with hyperthyroidism. Photophobia (sensitivity to light) is not a common symptom of hypothyroidism. Weight loss is more indicative of hyperthyroidism due to increased metabolism. Therefore, the correct answer is C: Lethargy, as it aligns with the expected findings in hypothyroidism.
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
- A. Dependent rubor
- B. Thick, deformed toenails
- C. Hair loss
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice B) and hair loss (choice C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.
A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?
- A. Take the medication with orange juice.
- B. Take the medication between meals.
- C. Take the medication on an empty stomach.
- D. Take the medication with milk.
Correct Answer: D
Rationale: The correct answer is D: Take the medication with milk. Betamethasone can cause stomach irritation, so taking it with milk can help reduce this side effect. Milk coats the stomach lining, providing a protective barrier. This helps to minimize the risk of gastrointestinal upset.
A: Taking the medication with orange juice is not recommended as it can increase stomach irritation due to its acidity.
B: Taking the medication between meals may not provide the same protective effect on the stomach lining as taking it with milk.
C: Taking the medication on an empty stomach can increase the risk of gastrointestinal irritation and should be avoided.
E, F, G: These options are not relevant to the administration of betamethasone.
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