Nokea
An adult client is on call for the operating room. The preoperative medication order is for meperidine HCl (Demerol) 100 mg IM and atropine 0.4 mg IM. The operating room calls at 11:00 A.M. and requests that the client be medicated. The nurse notes that the client last received meperidine for pain at 10:00 A.M. What is the most appropriate action for the nurse to take?
- A. Give the preoperative medication as ordered
- B. Give half the dose of meperidine and all of the atropine
- C. Check with the anesthesiologist before administering the medication
- D. Withhold both the meperidine and the atropine
Correct Answer: C
Rationale: Recent meperidine administration increases the risk of respiratory depression. Consulting the anesthesiologist ensures safe dosing.
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The client diagnosed with status asthmaticus is prescribed intravenous aminophylline, a bronchodilator. Which assessment data would warrant immediate intervention?
- A. The theophylline level is 12 mcg/mL.
- B. The client has expiratory wheezing.
- C. The client complains of muscle twitching.
- D. The client is refusing to eat the meal.
Correct Answer: C
Rationale: Muscle twitching indicates theophylline toxicity, requiring immediate intervention. Normal levels (10–20 mcg/mL), wheezing, or meal refusal are expected or less urgent.
An adult client has pulmonary tuberculosis. He is receiving INH 300 mg PO, ethambutol 1 g PO daily, and streptomycin 1 g IM three times a week. When he comes in for a checkup, he tells the nurse that he hates getting shots and his ears ring most of the time. What advice does the nurse expect will be given to this client?
- A. Take pyridoxine daily.
- B. Expect red-colored urine and feces.
- C. Stop the medications when your cough is gone.
- D. Take streptomycin by mouth instead of by injection.
Correct Answer: B
Rationale: Streptomycin’s ototoxicity may require discontinuation, not pyridoxine (used for INH). Red urine/feces is expected with rifampin, not listed here, but monitoring is key.
Ear drops have been ordered for a 10-month-old child. How should the nurse teach the mother to pull the baby's ear to straighten the ear canal?
- A. Down and back
- B. Down and forward
- C. Up and forward
- D. Up and back
Correct Answer: A
Rationale: In children under 3, pulling the ear down and back straightens the ear canal for proper ear drop administration.
The nurse is preparing to administer the morning dose of digoxin, a cardiac glycoside, to a client diagnosed with congestive heart failure. Which data would indicate the medication is effective?
- A. The apical heart rate is 72 beats per minute.
- B. The client denies having any anorexia or nausea.
- C. The client's blood pressure is 120/80 mm Hg.
- D. The client's lungs sounds are clear bilaterally.
Correct Answer: D
Rationale: Clear lung sounds indicate reduced fluid overload in CHF, a sign of digoxin’s effectiveness in improving cardiac output. HR, nausea, or BP are less specific.
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
- A. Pulverize all medications to a powdery condition
- B. Squeeze the tube before using it to break up stagnant liquids
- C. Cleanse the skin around the tube daily with hydrogen peroxide
- D. Flush adequately with water before and after using the tube
Correct Answer: D
Rationale: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only provides for good tube maintenance, it is flushing that moves medications through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.