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A patient is diagnosed with borderline hypertension and states a desire to make lifestyle changes to avoid needing to take medication. The nurse advises:
- A. Changing from weight-bearing exercise to yoga.
- B. Decreased fluid intake and increased potassium intake.
- C. Stress reduction and increased protein intake.
- D. Weight reduction and decreased sodium intake.
Correct Answer: D
Rationale: The correct answer is D: Weight reduction and decreased sodium intake. Weight reduction helps lower blood pressure by reducing strain on the heart and blood vessels. Decreasing sodium intake is crucial as high sodium levels can lead to increased blood pressure. Changing from weight-bearing exercise to yoga (choice A) may not be as effective in lowering blood pressure. Decreased fluid intake and increased potassium intake (choice B) might not directly address the root cause of hypertension. Stress reduction and increased protein intake (choice C) may not have a direct impact on blood pressure compared to weight reduction and sodium intake.
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The nurse evaluates the effects of warfarin by monitoring what lab test?
- A. Platelet count.
- B. Activated thromboplastin time (APT).
- C. Red blood count (RBC).
- D. Prothrombin time (PT) and international normalized ratio (INR).
Correct Answer: D
Rationale: The correct answer is D: Prothrombin time (PT) and international normalized ratio (INR). Warfarin is an anticoagulant medication that works by inhibiting vitamin K-dependent clotting factors. Monitoring PT and INR levels helps assess the effectiveness and safety of warfarin therapy. PT measures the time it takes for blood to clot, while INR standardizes PT results. Platelet count (A) assesses clot formation ability, not warfarin effects. APT (B) primarily evaluates the intrinsic pathway of coagulation. RBC count (C) measures oxygen-carrying capacity, unrelated to warfarin effects.
The nurse is caring for a patient who is receiving a high dose of intravenous azithromycin to treat an infection. The patient is also taking acetaminophen for pain. The nurse should expect to review which lab value when monitoring for this drug side effect?
- A. Complete blood count.
- B. Urinalysis.
- C. Electrolytes.
- D. Liver enzymes.
Correct Answer: D
Rationale: The correct answer is D: Liver enzymes. Azithromycin can cause liver toxicity as a side effect. Monitoring liver enzymes such as AST and ALT levels is crucial to detect any signs of liver damage. Acetaminophen is also metabolized in the liver, so combining it with azithromycin may increase the risk of liver injury. Checking liver enzymes helps the nurse assess the patient's liver function and adjust the medication regimen if necessary.
A: Complete blood count is not typically affected by azithromycin or acetaminophen.
B: Urinalysis is not relevant for monitoring liver toxicity.
C: Electrolytes are important but not specifically related to the side effects of azithromycin or acetaminophen in this scenario.
A nurse is providing discharge teaching for a patient who will be going home on cyclobenzaprine (Flexeril) prescribed for his acute musculoskeletal pain. The nurse will stress that the patient should avoid what?
- A. Taking antihistamines.
- B. Taking antiemetics.
- C. Taking antibiotics.
- D. Drinking alcohol.
Correct Answer: D
Rationale: The correct answer is D: Drinking alcohol. Cyclobenzaprine is a muscle relaxant that can cause drowsiness and dizziness. Alcohol can intensify these side effects, leading to impaired coordination and judgment. This can increase the risk of accidents and falls. It is important for the patient to avoid alcohol while taking cyclobenzaprine to prevent these adverse effects.
Choices A, B, and C are incorrect because there are no known interactions between cyclobenzaprine and antihistamines, antiemetics, or antibiotics that would pose a significant risk to the patient. It is essential to focus on the potential interactions that can have serious consequences, such as alcohol with cyclobenzaprine.
The nurse is caring for a patient that has seizure disorder. The nurse notes that the patient has reddened gums that bleed when oral care is given. The nurse recognizes this finding as:
- A. A sign of poor self-care.
- B. A drug interaction with aspirin.
- C. An adverse effect of the phenytoin.
- D. A symptom of hepatotoxicity.
Correct Answer: C
Rationale: The correct answer is C: An adverse effect of phenytoin. Phenytoin is an antiepileptic drug known to cause gingival hyperplasia, leading to reddened and bleeding gums. This is a common side effect of phenytoin due to its effect on gingival tissues. Poor self-care (choice A) may contribute to gingival issues, but in this case, the patient's gums are affected by a medication side effect. There is no indication in the question of aspirin use (choice B) or hepatotoxicity (choice D) causing the gum issues. Therefore, the most likely explanation is the adverse effect of phenytoin.
What action does the nurse take during the intervention stage of the nursing process related to drug therapy? (Select all that apply)
- A. Analyze the data collected.
- B. Collect a nursing history.
- C. Determine medication effectiveness.
- D. Document the medication.
- E. Administer the medication.
Correct Answer: C,D,E
Rationale: During the intervention stage of the nursing process related to drug therapy, the nurse's actions include determining medication effectiveness (C) to ensure the treatment is achieving its intended outcomes. Documenting the medication (D) is crucial for maintaining accurate records of administration and monitoring. Administering the medication (E) is essential for providing the prescribed treatment to the patient. Analyzing data (A) is typically done during the assessment phase, not the intervention phase. Collecting a nursing history (B) is part of the assessment phase. Other choices are not directly related to the intervention stage of drug therapy.