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An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide?
- A. Remind the client that feeling better is the therapeutic effect of the medication.
- B. Inform the client that gradual tapering must be used to discontinue the medication.
- C. Tell the client to discuss the medication side effects with the healthcare provider.
- D. Tell the client that the medication side effects will most likely diminish over time.
Correct Answer: B
Rationale: The best response for the nurse is to inform the client that gradual tapering must be used to discontinue the medication. Abrupt cessation of antidepressants can lead to withdrawal symptoms or a recurrence of depressive symptoms. Choice A is not the best response as it does not address the need for a proper discontinuation plan. Choice C is not the best response as it focuses solely on the side effects and does not address the discontinuation process. Choice D is not the best response because while side effects may diminish over time, the focus here should be on the safe discontinuation of the medication to prevent adverse effects.
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The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the procedure?
- A. Experiences facial swelling after eating crab
- B. Reports left chest wall pain prior to the admission
- C. Verbalizes a fear of being in a confined space
- D. Drank a glass of water
Correct Answer: A
Rationale: The correct answer is A. Allergy to shellfish can indicate a potential allergy to iodine, which is used in contrast dye for the procedure. This must be explored further to prevent an allergic reaction. Choice B is not directly related to the angioplasty procedure. Choice C pertains to claustrophobia, which can be addressed but is not directly related to the safety of the procedure. Choice D is a routine activity and does not pose a risk to the client during the procedure.
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
- A. Blood pressure is 90/40 mm Hg.
- B. Urine output is 30 mL over the last hour.
- C. Oral fluid intake is 100 mL over the last 8 hours.
- D. There is prolonged skin tenting over the sternum.
Correct Answer: A
Rationale: The correct answer is A: "Blood pressure is 90/40 mm Hg." A low blood pressure reading of 90/40 mm Hg indicates that the patient may be developing hypovolemic shock due to intravascular fluid loss from the burn injury. This finding is of utmost concern as it suggests systemic hypoperfusion, requiring immediate intervention to prevent complications. Choices B, C, and D also indicate signs of dehydration and the need to increase fluid intake; however, they are not as urgent as addressing the hypotension and potential shock presented in choice A.
A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first?
- A. Assess for side effects of the medication.
- B. Document the client's responses.
- C. Complete a medication error report.
- D. Determine if the pain was relieved.
Correct Answer: A
Rationale: This is a medication error, and the first step in addressing it is to assess for any side effects of the medication on the patient. Some analgesics can cause respiratory depression, so it is crucial to monitor for vital sign changes or respiratory distress. Once the patient is stable, the next steps would include contacting the provider, documenting the response, and completing a medication error report. Choices B, C, and D are not the immediate priority when dealing with a medication error. While documenting the client's responses and completing a medication error report are important, assessing for side effects and ensuring patient safety come first.
Which task can the registered nurse (RN) caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
- A. Administer IV antibiotics through the implantable port.
- B. Monitor the IV sites for redness, swelling, or tenderness.
- C. Remove the patient's nontunneled subclavian central venous catheter.
- D. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.
Correct Answer: B
Rationale: An experienced LPN/LVN can monitor IV sites for signs of infection because it falls within their education, experience, and scope of practice. Administering IV antibiotics through an implantable port, adjusting infusion rates, and removing central catheters are tasks that require RN level education and scope of practice. These activities involve a higher level of assessment, critical thinking, and potential complications that are typically within the RN's domain.
When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?
- A. The bibasilar breath sounds are decreased.
- B. The patellar and triceps reflexes are absent.
- C. The patient has been sleeping most of the day.
- D. The patient reports feeling 'sick to my stomach.'
Correct Answer: B
Rationale: The correct answer is B because the absence of patellar and triceps reflexes indicates potential magnesium toxicity, requiring immediate intervention. Nausea and lethargy are common side effects of elevated magnesium levels and should be reported, but they are not as critical as the loss of deep tendon reflexes. Decreased breath sounds suggest the need for coughing and deep breathing to prevent atelectasis, which is important but not as urgent as addressing magnesium toxicity.