Nokea
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish his supply every 3 months
- B. Take one every 15 minutes if pain occurs
- C. Leave the medication in the brown bottle
- D. Crush the medication and take with water
Correct Answer: C
Rationale: Nitroglycerin should be stored in its original brown bottle to protect it from light and maintain potency.
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If a client weighs 132 lb and has a caloric requirement of 28 calories per kg of body weight per day, what is the number of calories that the client needs each day to maintain body weight? Record your answer using a whole number.
Correct Answer: 1680
Rationale: Weight = 132 lb/ 2.2 = 60 kg. Calories = 60 kg X 28 cal/kg = 1,680 calories/day.
The nurse notes that a post-operative client's respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for:
- A. Pupillary changes
- B. Projectile vomiting
- C. Wheezing respirations
- D. Sudden, intense pain
Correct Answer: A
Rationale: After administering naloxone, the nurse should assess for pupillary changes, as reversal of opioid effects can cause sympathetic stimulation, affecting pupil size.
The nurse is caring for a client admitted with chest pain and atrial fibrillation. The nurse accidentally gives the client the wrong dose of digoxin. The client is monitored throughout the shift and no ill effects are noted. Which actions by the nurse are correct? Select all that apply.
- A. fill out an incident report and make a note of it in the nurse's notes
- B. print out rhythm strips every 2 hours and place on the client's chart
- C. fill out an incident report and notify the health care provider for further orders
- D. notify the health care provider at the end of the shift, since no ill effects were observed
- E. notify the pharmacy that they loaded the wrong dose in the automatic medication dispensing system
Correct Answer: C
Rationale: Filling out an incident report and notifying the provider immediately are necessary to address the medication error and ensure client safety, even if no ill effects were observed.
The client is diagnosed with multiple myloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
- A. Walk about a mile a day to prevent calcium loss.
- B. Increase the fiber in your diet.
- C. Report nausea to the doctor immediately.
- D. Drink at least eight large glasses of water a day.
Correct Answer: D
Rationale: Cyclophosphamide can cause hemorrhagic cystitis; adequate hydration (e.g., 8 glasses of water) helps prevent this.
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
- A. Tire easily
- B. Grow normally
- C. Need more calories
- D. Be more susceptible to viral infections
Correct Answer: A
Rationale: A ventricular septal defect causes increased pulmonary blood flow, leading to easy tiring due to cardiac workload.