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Complete the following sentence by using the lists of options. Upon analyzing the assessment findings, the nurse identifies that the client is at risk for _______ due to _______.
- A. concurrent medication use
- B. recent illness
- C. activity level
Correct Answer: A
Rationale: The correct answer is A: concurrent medication use. This is because identifying a client at risk for a condition due to concurrent medication use is crucial in nursing assessment. Medications can interact with each other, leading to adverse effects or reduced efficacy. Recent illness (B) and activity level (C) are important factors but do not directly relate to the risk due to medication use. The other choices (D, E, F, G) are irrelevant and do not address the potential risks associated with medication interactions. Thus, A is the most appropriate choice for identifying a client's risk based on assessment findings related to medication use.
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A nurse is teaching a client about the prescribed medication. Which of the following statements should the nurse include when teaching the client about the prescribed medication? Select all that apply.
- A. The medication can cause nausea
- B. so take with a meal.
- C. You can experience vivid nightmares.
- D. You may notice your urine becomes lighter in color.
- E. Consumption of a high-protein meal can reduce the effectiveness of the medication.
- F. You may initially notice an increase in involuntary movements.
- G. This medication can make you light-headed if you stand up too quickly from a seated or lying position.
Correct Answer: A, B, E,F
Rationale: The correct statements to include when teaching the client about the prescribed medication are A, B, E, and F. Statement A is important to mention as it informs the client about a potential side effect (nausea) of the medication. Statement B is crucial as taking the medication with a meal can help reduce the likelihood of nausea occurring. Statement E is relevant because high-protein meals can indeed interfere with the medication's effectiveness, so the client should be aware of this. Statement F is crucial as it prepares the client for a possible side effect of an increase in involuntary movements. These statements are important for the client to understand to ensure safe and effective medication use. Statements C, D, and G are incorrect as they do not pertain to the medication's side effects, interactions, or administration, making them irrelevant in this context.
Which of the following findings should indicate to the nurse that a client with myasthenia gravis taking neostigmine is experiencing an adverse effect?
- A. Tachycardia
- B. Oliguria
- C. Xerostomia
- D. Miosis
Correct Answer: D
Rationale: The correct answer is D: Miosis. Neostigmine is a cholinesterase inhibitor used to treat myasthenia gravis. Miosis, or excessive constriction of the pupil, is a sign of cholinergic crisis which can occur due to neostigmine overdose. This adverse effect indicates excessive stimulation of the parasympathetic nervous system, leading to symptoms such as increased salivation, bronchoconstriction, and miosis. Tachycardia (A) is not typically associated with neostigmine use, oliguria (B) is not a common adverse effect, and xerostomia (C) is the opposite of the expected effect of increased salivation due to cholinergic stimulation.
A nurse is preparing to administer PO sodium polystyrene sulfonate to a client who has hyperkalemiWhich of the following actions should the nurse plan to take?
- A. Hold the client's other oral medications for 1 hour post-administration.
- B. Inform the client that this medication can turn stool a light tan color.
- C. Keep the client's solution in the refrigerator for up to 72 hours.
- D. Monitor the client for constipation.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client for constipation. Sodium polystyrene sulfonate is a medication used to treat hyperkalemia by binding excess potassium in the intestines for elimination. Constipation is a common side effect, as the medication can cause a decrease in bowel motility. The nurse should monitor the client for signs of constipation, such as abdominal discomfort, decreased frequency of bowel movements, or difficulty passing stools. This is essential to prevent complications such as bowel obstruction. Holding the client's other oral medications, informing about stool color changes, or refrigerating the solution are not relevant actions for administering sodium polystyrene sulfonate.
A nurse is caring for a client who received 0.9% sodium chloride 1 L over 4 hr instead of over 8 hr as prescribeWhich of the following information should the nurse enter as a complete documentation of the incident?
- A. IV fluid infused over 4 hr instead of the prescribed 8 hr. Client tolerated fluids well, provider notified.
- B. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
- C. 1 L of 0.9% sodium chloride completed at 0900. Client denies shortness of breath.
- D. IV fluid initiated at 0500. Lungs clear to auscultation.
- E. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. This choice clearly states the key information - the type of IV fluid, volume, and duration of infusion.
2. Mentioning that vital signs were stable indicates client's safety was monitored.
3. Notifying the provider is crucial for any deviation from the prescribed treatment plan.
Incorrect Choices:
A. Fails to mention the type of IV fluid or client's vital signs, lacks detail.
C. Although it mentions the completion time, it does not address the deviation or client's tolerance.
D. Provides irrelevant information about the initiation time and lung assessment.
E. Similar to choice B, but lacks mentioning the infusion duration which is critical for documenting the incident.
A nurse administers a dose of metformin to a client instead of the prescribed dose of metoclopramidWhich of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Notify the provider.
- C. Check the client's blood glucose.
- D. Fill out an incident report.
Correct Answer: C
Rationale: The correct answer is C: Check the client's blood glucose. This is the first action the nurse should take because metformin is used to treat diabetes and can lower blood sugar levels. Checking the client's blood glucose will help assess if the client is experiencing hypoglycemia due to the medication error. Reporting the incident to the charge nurse (A) and filling out an incident report (D) are important steps, but assessing the client's immediate condition takes priority. Notifying the provider (B) can be done after ensuring the client's safety. The other options are not relevant to addressing the immediate concern of potential hypoglycemia.