Nokea
Prior to administering an oral dose of methylprednisolone, the nurse determines the client's serum total calcium level is 5.5 mg/dL (1.375 mmol/L). What action is most important for the nurse to take?
- A. Administer the medication with a glass of milk.
- B. Begin tapering the drug dose per protocol.
- C. Notify the healthcare provider of the finding.
- D. Teach the client about foods high in calcium.
Correct Answer: C
Rationale: A calcium level of 5.5 mg/dL is critically low, requiring immediate provider notification for evaluation. Milk administration, tapering, or dietary teaching are not immediate priorities.
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Ferrous sulfate elixir is prescribed for a client with iron deficiency anemia. Which instruction should the nurse provide this client about taking the liquid medication?
- A. Use a straw to ingest.
- B. Swallow undiluted.
- C. Mix with an antacid.
- D. Take with a glass of milk.
Correct Answer: A
Rationale: Using a straw prevents tooth staining from ferrous sulfate. Undiluted swallowing risks staining, antacids reduce absorption, and milk inhibits iron absorption due to calcium.
History and physical
POD 5
1015
The client is alert and oriented. Rates her pain a 3 on a 0 to 10 pain scale. The client says that she has fullness in her abdomen. Heart sounds are regular and rhythmic. Pulses 1+ in all extremities and equal. Her last bowel movement was POD 2. Healthcare provider notified. The client voided 150 mL of urine.
1100
Bisacodyl suppository given as prescribed.
Reported slight rectal burning when administered.
Nurses notes
POD 5
1015
The client is alert and oriented. Rates her pain a 3 on a 0 to 10 pain scale. The client says that she has fullness in her abdomen. Heart sounds are regular and rhythmic. Pulses 1+ in all extremities and equal. Her last bowel movement was POD 2. Healthcare provider notified. The client voided 150 mL of urine.
1100
Bisacodyl suppository given as prescribed.
Reported slight rectal burning when administered.
1200
Rates her pain a 7 on a 0 to 10 pain scale. Pulses 1+ in all extremities and equal. Morphine given as prescribed. She asked to use the restroom but felt dizzy. Voided 600 mL urine in the bedpan.
Flowsheet
Vital Signs
POD 5
1015
Temperature 97.2° F (36.2° C) orally
Heart rate 77 beats/minute
Respiratory rate 14 breaths/minute
Blood pressure 119/75 mm Hg
1200
• Temperature 97° F (36.1° C) orally
Review H and P, nurse's notes, flow sheet, and prescriptions. Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have only one option selected.
- A. Reported slight rectal burning sensation: Non-therapeutic side effect
- B. Large, soft stool: Therapeutic result
- C. Dizziness: Non-therapeutic side effect
- D. Pain level of 3 on a 0 to 10 pain scale: Unrelated finding
- E. 600ml of urine: Unrelated finding
- F. Abdomen soft and flat: Unrelated finding
- G. Respiratory rate 13 breaths/min: Unrelated finding
Correct Answer:
Rationale: The question refers to bisacodyl, not lactulose. A: Rectal burning is a bisacodyl side effect. B: Soft stool is the therapeutic effect. C: Dizziness may relate to morphine, not bisacodyl. D, E, F, G: Pain, urine output, abdomen, and respiratory rate are unrelated to bisacodyl.
A client with a history of anaphylactic reaction to penicillin receives a prescription for cephalexin 500 mg PO twice daily. Which action should the nurse take?
- A. Administer the medication as prescribed.
- B. Monitor the client for a rash or hives.
- C. Contact the healthcare provider.
- D. Give with prescribed antihistamine.
Correct Answer: B
Rationale: Cephalexin may cause cross-reactivity in penicillin-allergic clients, so monitoring for allergic reactions like rash or hives is critical. Administering without monitoring, contacting the provider immediately, or giving antihistamines prophylactically are less appropriate.
A female client with osteoporosis has been taking a weekly dose of oral risedronate for several weeks. The client calls the clinic nurse to report increasing 'heartburn.' How should the nurse respond?
- A. Ask the client to describe how she takes the medication.
- B. Remind the client to take the medication with plenty of water.
- C. Advise the client to go to the nearest emergency department.
- D. Suggest use of an antacid two hours after the medication.
Correct Answer: A
Rationale: Risedronate can cause esophageal irritation if not taken properly. Assessing the client’s administration technique (e.g., with water, staying upright) identifies potential causes of heartburn, guiding further intervention.
The nurse is caring for a client with atrial fibrillation who receives a prescription for warfarin. The international normalized ratio (INR) is 2.8. Which action should the nurse take?
- A. Obtain another blood sample.
- B. Give the next scheduled dose.
- C. Monitor for signs of bleeding.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: An INR of 2.8 is within the therapeutic range for atrial fibrillation, but monitoring for bleeding is critical as a routine precaution. Repeating the sample, giving the dose, or notifying the provider are less immediate.