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An adult is hospitalized for an acute attack of gout. Which medication should the nurse expect to administer?
- A. Morphine
- B. Colchicine
- C. Allopurinol
- D. Acetaminophen
Correct Answer: B
Rationale: Colchicine is used to treat acute gout attacks by reducing inflammation, unlike allopurinol, which prevents attacks.
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The client received Narcan, a narcotic antagonist, following a colonoscopy. Which action by the nurse has the highest priority?
- A. Document the occurrence in the nurse's notes.
- B. Prepare to administer narcotic medication IV.
- C. Administer oxygen via nasal cannula.
- D. Assess the client every 15 to 30 minutes.
Correct Answer: D
Rationale: Narcan reverses opioids but has a short half-life; frequent assessment (15–30 min) monitors for re-sedation or respiratory depression, the priority.
The client's vital signs are T 99.2°F, AP 59, R 20, and BP 108/72. Which medication would the nurse question administering?
- A. Theo-Dur, a bronchodilator.
- B. Inderal, a beta blocker.
- C. Ampicillin, an antibiotic.
- D. Cardizem, a calcium channel blocker.
Correct Answer: B
Rationale: Inderal (propranolol) slows HR; an apical pulse of 59 warrants holding it, per guidelines, to avoid bradycardia. Other meds are unaffected by HR.
The nurse is monitoring a client receiving a thrombolytic agent, alteplase (Activase tissue plasminogen activator), for treatment of a myocardial infarction. What outcome indicates the client is receiving adequate therapy within the first hours of treatment?
- A. Absence of a dysrhythmia (or arrhythmia)
- B. Blood pressure reduction
- C. Cardiac enzymes are within normal limits
- D. Return of ST segment to baseline on ECG
Correct Answer: D
Rationale: Return of ST segment to baseline on ECG. Improved perfusion should result from this medication, along with the reduction of ST segment elevation.
The client is diagnosed with essential hypertension and is receiving a calcium channel blocker. Which assessment data would warrant the nurse holding the client's medication?
- A. The client's oral temperature is 102°F.
- B. The client complains of a dry, nonproductive cough.
- C. The client's blood pressure reading is 106/76.
- D. The client complains of being dizzy when getting out of bed.
Correct Answer: D
Rationale: Dizziness on standing suggests orthostatic hypotension, a calcium channel blocker side effect, warranting holding the dose to prevent falls. Fever, cough, or BP are less critical.
A 6-year-old child is seen in the emergency room after stepping on a rusty nail. He has received no immunizations. What should the nurse expect to give him immediately to prevent a tetanus infection?
- A. Tetanus toxoid
- B. DTaP
- C. Immune serum globulin
- D. Penicillin
Correct Answer: C
Rationale: Immune serum globulin provides immediate passive immunity against tetanus in an unimmunized child.