Nokea
Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?
- A. Limit fluids to 500 mL/day.
- B. Administer 2 hours before meals.
- C. Observe for skin rash and diarrhea.
- D. Monitor blood pressure, pulse.
Correct Answer: C
Rationale: Sulfasalazine commonly causes skin rash and diarrhea, which should be monitored. The other options are not relevant nursing implications.
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A client with a history of a burn injury is receiving Collagenase (Santyl). The nurse should:
- A. Apply the ointment to healthy skin
- B. Cover the wound with a dry dressing
- C. Clean the wound before application
- D. Expose the wound to air after application
Correct Answer: C
Rationale: Collagenase is applied to debride burn wounds, requiring a clean wound bed for effectiveness. It’s applied only to the wound, covered with a moist dressing, and not exposed to air.
A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
- A. Intake and output
- B. Calcium
- C. Potassium
- D. Magnesium
Correct Answer: C
Rationale: Furosemide is a nonpotassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity.
A client has developed diabetes insipidus after removal of a pituitary tumor. Which finding would the nurse expect?
- A. Polyuria
- B. Hypertension
- C. Polyphagia
- D. Hyperkalemia
Correct Answer: A
Rationale: Diabetes insipidus causes polyuria due to deficient antidiuretic hormone, leading to excessive water loss. Hypertension (B), polyphagia (C), and hyperkalemia (D) are not typical.
The physician orders Zestril (lisinopril) and Lasix (furosemide) to be administered at the same time to a client with hypertension. The nurse should:
- A. Question the order
- B. Administer the medications as ordered
- C. Administer the medications separately
- D. Contact the pharmacy
Correct Answer: B
Rationale: Lisinopril (an ACE inhibitor) and furosemide (a diuretic) are commonly prescribed together for hypertension to reduce blood pressure synergistically. Administering them as ordered is appropriate as there is no contraindication to concurrent use.
The client is admitted with a diagnosis of gestational diabetes. Which intervention is most appropriate?
- A. Monitor blood glucose levels
- B. Administer tocolytics
- C. Monitor fetal heart tones
- D. All of the above
Correct Answer: D
Rationale: Gestational diabetes requires blood glucose monitoring to maintain control fetal heart tone monitoring to assess fetal well-being and potentially other interventions. Tocolytics are not indicated unless preterm labor occurs.