Nokea
Which of the following laboratory results should the nurse report to the provider?
- A. A client who has a prescription for heparin and an aPTT of 90 seconds (normal range 30-40 sec)
- B. A client who has a prescription for heparin and an aPTT of 65 seconds (normal range 30-40 sec)
- C. A client who has a prescription for warfarin and an INR of 3.0 (normal range 0.8-1.1)
- D. A client who has a prescription for warfarin and an INR of 2.0 (normal range 0.8-1.1)
Correct Answer: A
Rationale: The correct answer is A. An aPTT of 90 seconds is above the normal range of 30-40 sec, indicating the client is at risk for bleeding due to excessive anticoagulation with heparin. This result should be reported to the provider immediately for further evaluation and possible adjustment of the heparin dose to prevent bleeding complications. Choices B, C, and D all fall within the normal range for their respective medications, so they do not require immediate reporting.
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Which of the following adverse effects should the nurse include in the teaching for a client who is to begin taking tamoxifen for the treatment of breast cancer?
- A. Urinary retention
- B. Constipation
- C. Bradycardia
- D. Hot flashes
Correct Answer: D
Rationale: The correct answer is D: Hot flashes. Tamoxifen is known to cause hot flashes as a common side effect due to its estrogen-blocking properties. This is important to include in teaching as it can affect the client's quality of life. Urinary retention (A), constipation (B), and bradycardia (C) are not commonly associated with tamoxifen use. Hot flashes are a well-documented side effect, making it the most appropriate choice for client education.
A nurse is teaching a client about cyclobenzaprinWhich of the following client statements should indicate to the nurse that the teaching about cyclobenzaprine was effective?
- A. I will have increased saliva production
- B. I will continue taking the medication until the rash disappears
- C. I will taper off the medication before discontinuing it
- D. I will report any urinary incontinence
Correct Answer: C
Rationale: Correct Answer: C. "I will taper off the medication before discontinuing it."
Rationale: Tapering off cyclobenzaprine is important to prevent withdrawal symptoms due to its muscle relaxant properties. Abruptly stopping the medication can lead to adverse effects. This statement indicates understanding of proper medication management.
Incorrect Choices:
A: Increased saliva production is not a common side effect of cyclobenzaprine.
B: Continuing the medication until the rash disappears is not relevant to cyclobenzaprine.
D: Reporting urinary incontinence is important but not specifically related to cyclobenzaprine teaching.
A nurse is assessing a client after administering a second dose of cefazolin IV. The nurse notes the client has anxiety, hypotension. and dyspneWhich of the following medications should the nurse administer first?
- A. Diphenhydramine
- B. Albuterol inhaler
- C. Epinephrine
- D. Prednisone
Correct Answer: C
Rationale: The correct answer is C: Epinephrine. Epinephrine is the first-line treatment for anaphylaxis, which can present with symptoms such as anxiety, hypotension, and dyspnea following administration of a medication like cefazolin. Epinephrine acts quickly to reverse the severe allergic reaction by constricting blood vessels, increasing blood pressure, and opening up the airways to improve breathing. Diphenhydramine (A) is an antihistamine that can be used as an adjunct therapy but is not the first choice in an acute anaphylactic reaction. Albuterol inhaler (B) is used for bronchodilation in asthma, not for managing anaphylaxis. Prednisone (D) is a corticosteroid that may be used later in the treatment process to prevent a late-phase reaction but is not the initial treatment for anaphylaxis.
Which of the following actions of sucralfate should the nurse include in the teaching for a client who is to start a new prescription for sucralfate for peptic ulcer disease?
- A. Decreases stomach acid secretion
- B. Neutralizes acids in the stomach
- C. Forms a protective barrier over ulcers
- D. Treats ulcers by eradicating H. pylori
Correct Answer: C
Rationale: The correct answer is C: Forms a protective barrier over ulcers. Sucralfate works by forming a protective barrier over ulcers in the stomach and small intestine, providing a physical barrier to prevent further damage from stomach acid. This action helps promote healing of the ulcers. Choices A, B, and D are incorrect because sucralfate does not decrease stomach acid secretion, neutralize acids in the stomach, or treat ulcers by eradicating H. pylori bacteria. It is important for the nurse to educate the client on the mechanism of action of sucralfate to ensure understanding and adherence to the treatment plan.
A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift and the client received atenolol instead of allopurinol.Which of the following actions should the nurse take first when discovering a medication error in which atenolol was given instead of allopurinol to a client with gout?
- A. Obtain the client's blood pressure
- B. Contact the client's provider
- C. Inform the charge nurse
- D. Complete an incident report
Correct Answer: A
Rationale: The correct action for the nurse to take first in this situation is to obtain the client's blood pressure (Choice A). This is important because atenolol is a beta-blocker that can lower blood pressure, and giving it to a client with gout instead of allopurinol can potentially result in adverse effects or exacerbate the underlying condition. By obtaining the client's blood pressure, the nurse can assess if there have been any significant changes since the administration of the incorrect medication. This immediate assessment allows the nurse to monitor for any potential adverse effects and take appropriate action if necessary. Contacting the client's provider (Choice B) would be important, but assessing the immediate impact on the client's health by checking the blood pressure takes precedence. Informing the charge nurse (Choice C) and completing an incident report (Choice D) are important steps to take after addressing the immediate health concern of the client.