Nokea
Which of the following statements should the nurse include when teaching the client about the prescribed medication?
- A. The medication can cause nausea, so take with a meal.
- B. You can experience vivid nightmares.
- C. You may notice your urine becomes lighter in color.
- D. Consumption of a high protein meal can reduce the effectiveness of the medication.
- E. You may initially notice an increase in involuntary movements.
Correct Answer: A
Rationale: The correct answer is A because taking the medication with a meal can help reduce nausea. This statement is important to ensure client compliance and improve medication tolerance. Choice B is incorrect as vivid nightmares are not a common side effect of the medication. Choice C is incorrect as urine color change is not relevant to this medication. Choice D is incorrect as high protein meals do not affect medication effectiveness. Choice E is incorrect as an increase in involuntary movements is not expected with this medication.
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A nurse is assessing a client's IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?
- A. Slow the IV solution rate
- B. Initiate a new IV distal to the initial site
- C. Maintain the extremity below the level of the heart
- D. Apply a warm, moist compress
Correct Answer: D
Rationale: The correct action is to apply a warm, moist compress (Choice D). This helps improve circulation and reduce edema by promoting vasodilation and enhancing tissue perfusion. Cooling and edematous IV sites indicate impaired circulation, which can lead to complications like phlebitis. Slowing the IV rate (Choice A) may not address the underlying issue. Initiating a new IV distal to the initial site (Choice B) may not improve circulation in the affected area. Maintaining the extremity below heart level (Choice C) can worsen edema.
A nurse is providing teaching to a client who has a new prescription for theophylline, a sustained-released capsule. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can take my medication in the morning with my coffee.
- B. I may sprinkle the medication in applesauce.
- C. I should limit my fluid intake while on this medication.
- D. I will need to have blood levels drawn.
Correct Answer: D
Rationale: Answer D is correct because monitoring blood levels is crucial for theophylline therapy due to its narrow therapeutic range. Regular monitoring helps ensure the drug is at a safe and effective level in the body. Taking the medication with food or fluids, as indicated in choices A and C, can affect its absorption or metabolism, leading to suboptimal effects or toxicity. Sprinkling the medication in applesauce, as in choice B, can alter the drug's sustained-release mechanism, causing rapid release and possible adverse effects. Therefore, choice D is the best option for ensuring theophylline therapy's safety and efficacy.
A nurse is administering 4 mg of hydromorphone to a client by mouth every 4 hr. The medication is provided as hydromorphone 8 mg per tablet. Which of the following actions is appropriate for the nurse to take?
- A. Return the remaining medication to the facility's pharmacy.
- B. Store the remaining half of the pill in the automated medication dispensing system.
- C. Place the remaining half of the pill in the unit dose package.
- D. Dispose of the remaining medication while another nurse observes.
Correct Answer: D
Rationale: The correct answer is D: Dispose of the remaining medication while another nurse observes. This is the appropriate action because hydromorphone is a controlled substance with high abuse potential. The nurse should follow proper medication disposal protocols to prevent diversion or misuse. Returning the medication to the pharmacy (choice A) may not ensure proper disposal. Storing the remaining half of the pill in the automated medication dispensing system (choice B) or placing it in the unit dose package (choice C) could lead to unauthorized access. Disposing of the medication while another nurse observes (choice D) ensures accountability and adherence to safety measures.
A nurse is reviewing a client's 0800 laboratory values at 1100. The nurse notes that the client received heparin at 1000. Which of the following laboratory values warrants an incident report?
- A. ePTT 90 seconds
- B. Hgb 16 g/dL
- C. INR 1.6
- D. WBC 6,000/mm3
Correct Answer: A
Rationale: The correct answer is A: ePTT 90 seconds. This value indicates a higher than normal clotting time, which could potentially lead to bleeding complications due to excessive anticoagulation from heparin. The other values (B, C, D) are within normal ranges and do not indicate an immediate risk or adverse outcome related to heparin administration. An incident report is necessary to document and address the elevated ePTT to ensure appropriate interventions are taken to prevent harm to the patient.
A nurse is receiving a medication prescription by telephone from a provider. The provider states, 'Administer 6 milligrams of morphine IV push every 3 hours as needed for acute pain.' How should the nurse transcribe the prescription in the client's medical record?
- A. Morphine 6 mg IV push every 3 hr PRN acute pain
- B. MSO 6 mg IV push every 3 hr PRN acute pain
- C. MS 6 mg IV push every 3 hr PRN acute pain
- D. Morphine 6.0 mg IV push every 3 hr PRN acute pain
Correct Answer: A
Rationale: The correct answer is A: Morphine 6 mg IV push every 3 hr PRN acute pain. This transcription accurately reflects the medication (morphine), dose (6 mg), route (IV push), frequency (every 3 hours), and indication (acute pain). "PRN" indicates as needed. Choice B is incorrect because "MSO" is not morphine. Choice C is incorrect because "MS" is not specific to morphine. Choice D is incorrect because adding a decimal point (6.0 mg) is unnecessary and can lead to dosing errors.