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For each of the following client statements, click to specify whether the statement indicates an understanding or no understanding of the teaching.
- A. If I experience black stools, I should notify my provider.
- B. I should rinse my mouth after taking this medication.
- C. I should avoid taking antacids while on this medication.
- D. I should take this medication with orange juice.
- E. I should take my medication on an empty stomach.
Correct Answer: D
Rationale: [1, 0, 0, 0]
The correct answer is D. Taking medication with orange juice is often mentioned for specific medications that require acidic environments for absorption. This statement demonstrates an understanding of the medication regimen. Choices A, B, and C are incorrect as they do not directly relate to the medication instructions. Choice E is also incorrect as it contradicts the specific instruction provided in choice D.
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A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 lb.) since the last visit 2 days ago. Which of the following actions should the nurse take first?
- A. Encourage the client to dangle the legs while sitting in a chair
- B. Teach the client about foods low in sodium
- C. Determine medication adherence by the client
- D. Notify the provider of the client's weight gain
Correct Answer: D
Rationale: The correct answer is D: Notify the provider of the client's weight gain. This is the first action the nurse should take because sudden weight gain in a client with heart failure could indicate fluid retention, which may worsen the client's condition. By notifying the provider, the nurse can ensure timely intervention to adjust the medication or treatment plan. Encouraging leg dangling (A) may help with circulation but does not address the immediate concern of weight gain. Teaching about low-sodium foods (B) is important for long-term management but not the priority at this moment. Determining medication adherence (C) is important but should come after addressing the immediate weight gain issue.
A nurse is preparing to administer potassium chloride elixir 20 mEq/day PO to divide equally every 12 hr. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose? (Round to the nearest tenth.)
Correct Answer: 7.5
Rationale: The correct answer is 7.5 mL. To determine this, first calculate the total daily dose: 20 mEq/day ÷ 2 doses/day = 10 mEq/dose. Next, find the mL per dose using the available concentration: 10 mEq ÷ 6.7 mEq/5 mL = 7.46 mL, which rounds to 7.5 mL. This ensures the patient receives the correct dose of potassium chloride elixir. Other choices are incorrect because they do not follow the correct calculation or rounding process, leading to potential under or overdosing.
A nurse is teaching a client about oral contraceptive. Which of the following information should the nurse include in the teaching?
- A. Abdominal pain is an expected adverse effect of oral contraceptives
- B. It can take up to 1 year to become pregnant after stopping an oral contraceptive
- C. Some herbal supplements can decrease the effectiveness of an oral contraceptive
- D. A pelvic examination is needed prior to starting an oral contraceptive
Correct Answer: C
Rationale: The correct answer is C: Some herbal supplements can decrease the effectiveness of an oral contraceptive. The nurse should include this information in the teaching to ensure the client understands potential interactions. Herbal supplements like St. John's Wort can reduce the effectiveness of oral contraceptives by increasing their metabolism. This can lead to contraceptive failure and unintended pregnancy. Option A is incorrect because abdominal pain is not an expected adverse effect of oral contraceptives. Option B is incorrect as fertility typically returns quickly after stopping oral contraceptives, not taking up to a year. Option D is incorrect as a pelvic examination is not always necessary before starting oral contraceptives.
A nurse is monitoring laboratory values for a client who has chronic heart failure and is receiving digoxin. Which of the following values should the nurse report to the provider?
- A. Sodium 1.38 mEq/dL
- B. Magnesium 1.5 mEq/L
- C. BUN level 10 mg/dL
- D. Potassium 2.9 mEq/L
Correct Answer: D
Rationale: The correct answer is D: Potassium 2.9 mEq/L. Low potassium levels can predispose the client to digoxin toxicity, leading to potentially life-threatening arrhythmias. Hypokalemia increases the risk of digoxin binding to cardiac tissue, enhancing its toxic effects. The nurse should report this value to the provider immediately for prompt intervention to prevent complications.
Incorrect Choices:
A: Sodium 1.38 mEq/dL - Low sodium levels are not directly related to digoxin toxicity.
B: Magnesium 1.5 mEq/L - While magnesium levels are important for cardiac function, they are not as directly linked to digoxin toxicity as potassium.
C: BUN level 10 mg/dL - BUN levels are not specific indicators of digoxin toxicity.
Summary: Potassium levels are crucial to monitor in clients taking digoxin due to the risk of toxicity. Sodium, magnesium, and BUN levels are important but not as
A nurse is assessing a client who has hypermagnesemia. Which of the following medications should the nurse prepare to administer?
- A. Protamine sulfate
- B. Acetylcysteine
- C. Calcium gluconate
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Calcium gluconate. In hypermagnesemia, there is an excess of magnesium in the blood, leading to muscle weakness, cardiac arrhythmias, and respiratory depression. Calcium gluconate is the antidote for hypermagnesemia as it works by antagonizing the effects of magnesium. By administering calcium gluconate, the nurse can help reverse the symptoms associated with hypermagnesemia and restore normal calcium levels in the body. Protamine sulfate (Choice A) is used to reverse the effects of heparin, acetylcysteine (Choice B) is used as an antidote for acetaminophen overdose, and flumazenil (Choice D) is used to reverse the effects of benzodiazepines. These medications are not indicated for hypermagnesemia.