Nokea
During a home visit, the nurse assesses a client with Alzheimer's disease who recently started a new prescription for rivastigmine. The caregiver reports that the client seems to be thinking more clearly but is not sleeping well at night. Which action should the nurse take?
- A. Advise the caregiver that the purpose of the medication is to promote sleep, so a change in medication may be needed.
- B. Explain to the caregiver that insomnia is a common and temporary side effect when the medication is first started.
- C. Instruct the caregiver to withhold the medication until the dosage can be decreased to ensure the client's safety.
- D. Notify the healthcare provider that the dosage of the medication may need to be increased to manage the client's insomnia.
Correct Answer: B
Rationale: Insomnia is a common, often temporary side effect of rivastigmine. Explaining this reassures the caregiver. Rivastigmine is for cognition, not sleep, and withholding or increasing the dose is inappropriate without provider guidance.
You may also like to solve these questions
A client is receiving miotics for the treatment of open-angle glaucoma. The nurse determines that a priority nursing problem is 'risk for injury.' This nursing problem is based on which etiology?
- A. Increased frequency of lacrimation.
- B. Decreased night vision.
- C. Increased sensitivity to light.
- D. Diminished color perception.
Correct Answer: B
Rationale: Miotics constrict the pupil, reducing night vision and increasing injury risk in low-light conditions. Lacrimation, photophobia, and color perception changes are less directly linked to injury risk.
The nurse prepares to give 2 units of insulin lispro. Which should the nurse double check with a second nurse? Select all that apply.
- A. The dose of insulin drawn up in the syringe
- B. The expiration date on the insulin vial
- C. The type of insulin to be administered
- D. The sliding scale insulin lispro prescription
- E. The insulin concentration
- F. The insulin vial for color and clarity
- G. The history and physical with the diabetes diagnosis listed
Correct Answer: A,B,C,D,E,F
Rationale: Dose, type, prescription, concentration, vial clarity, and expiration ensure safe insulin administration. B and G are standard nurse assessments, not requiring double-checking.
Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions.Click to mark whether the assessment finding represents a therapeutic result of the mannitol administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.
- A. Peripheral edema: Non-therapeutic side effect
- B. Potassium 2.9: Non-therapeutic side effect
- C. Urine output 280 ml: Therapeutic result
- D. Heart rate 79: Unrelated finding
- E. Intracranial pressure 11mmHg: Therapeutic result
- F. Oxygen saturation: Unrelated finding
Correct Answer:
Rationale: A: Edema is a mannitol side effect. B: Hypokalemia is a side effect. C: Increased urine output is therapeutic. D: Normal heart rate is unrelated. E: Reduced intracranial pressure is therapeutic. F: Normal oxygen saturation is unrelated.
When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. Which action should the nurse take?
- A. Administer an oral analgesic and evaluate its effectiveness before applying the new patch.
- B. Apply the new patch in a different location after removing the original patch.
- C. Place the patch on the client's shoulder and leave both patches in place for 12 hours.
- D. Remove the patch and consult with the healthcare provider about the client's pain resolution.
Correct Answer: B
Rationale: Fentanyl transdermal patches should be applied to a different location after removing the original patch to ensure consistent pain management while preventing skin irritation or overdose. Administering an oral analgesic is unnecessary if the client has no pain, leaving both patches risks overdose, and consulting the provider is not immediate unless opioid need is reassessed.
A client with chronic kidney disease (CKD) is receiving calcium acetate 667 mg PO. A decrease in which blood value indicates to the nurse that the medication is having the desired effect?
- A. pH.
- B. Phosphate.
- C. Potassium.
- D. Calcium.
Correct Answer: B
Rationale: Calcium acetate lowers phosphate levels in CKD by binding dietary phosphate. A decreased phosphate level indicates effectiveness. pH, potassium, and calcium are not primary targets.