Nokea
Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Click to mark whether the assessment finding represents a therapeutic result of the minoxidil administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have one option selected.
- A. Dizziness while sitting up: Non-therapeutic side effect
- B. Blood glucose 218mg/dl: Unrelated finding
- C. Mouth dryness: Non-therapeutic side effect
- D. Blood pressure 162/111mmHg: Therapeutic result
- E. Heart rate 99: Non-therapeutic side effect
- F. Pain of 1 out of 10: Unrelated finding
- G. Urine output 600ml: Unrelated finding
Correct Answer:
Rationale: A: Dizziness is a minoxidil side effect (hypotension). B: High glucose relates to diabetes. C: Dry mouth is a possible side effect. D: Lowered blood pressure is therapeutic. E: Tachycardia is a side effect. F: Pain reduction relates to ibuprofen. G: Urine output is unrelated.
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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.
A client with cystitis receives a prescription for phenazopyridine. Which information should the nurse explain to the client about its therapeutic effect?
- A. Provides an analgesic effect for irritated bladder mucosa.
- B. Eliminates urinary bacteria.
- C. Calms spasms in the urinary tract.
- D. Use the medication after voiding after sexual intercourse.
Correct Answer: A
Rationale: Phenazopyridine is a urinary analgesic that relieves pain, burning, and discomfort from irritated bladder mucosa in cystitis. It does not have antibacterial properties, calm spasms, or require specific timing related to sexual intercourse.
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.
Before administering the initial dose of sumatriptan succinate to a client with a migraine headache, it is most important to determine if the client's history includes which problem?
- A. Coronary artery disease.
- B. Irritable bowel syndrome.
- C. Seasonal allergic rhinitis.
- D. Type 2 diabetes mellitus.
Correct Answer: A
Rationale: Sumatriptan causes vasoconstriction, which can exacerbate coronary artery disease, making this history critical to assess. IBS, rhinitis, and diabetes are not contraindications.
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.