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The client diagnosed with bipolar disorder has been taking valproic acid (Depakote), an anticonvulsant, for four (4) months. Which assessment data would warrant the medication being discontinued?
- A. The client's eyes are yellow.
- B. The client has mood swings.
- C. The client's BP is 164/94.
- D. The client's serum level is 75 mcg/mL.
Correct Answer: A
Rationale: Yellow eyes suggest hepatotoxicity, a serious valproic acid side effect, warranting discontinuation. Mood swings, hypertension, or normal levels are less critical.
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The client diagnosed with angina must receive a two (2)-inch nitroglycerin paste (Nitro-Bid) application. Which interventions should the nurse implement? Select all that apply.
- A. Wear gloves when administering.
- B. Remove the old Nitro-Bid paper.
- C. Apply the paper on a hairy spot.
- D. Put medication only on the legs.
- E. Report any headache to the HCP.
Correct Answer: A,B
Rationale: Gloves prevent nurse absorption, and removing old paste ensures accurate dosing. Hairy spots reduce adhesion, leg-only application is incorrect, and headaches are expected.
The client diagnosed with diabetes insipidus is receiving vasopressin intranasally. Which assessment data indicate the medication is effective?
- A. The client reports being able to breathe through the nose.
- B. The client complains of being thirsty all the time.
- C. The client has a blood glucose of 99 mg/dL.
- D. The client is urinating every three (3) to four (4) hours.
Correct Answer: D
Rationale: Vasopressin reduces polyuria in diabetes insipidus; urination every 3–4 hours indicates effectiveness. Nasal breathing, thirst, or glucose are unrelated.
The charge nurse is observing the new graduate administering a fentanyl (Duragesic) patch to a client diagnosed with cancer. Which action by the new graduate requires intervention by the charge nurse?
- A. The new graduate documents the date and time on the patch.
- B. The new graduate removes the patch 24 hours after it is placed on the client.
- C. The new graduate rotates the application site on the client's body.
- D. The new graduate checks the client's name band and date of birth.
Correct Answer: B
Rationale: Fentanyl patches last 72 hours; removing at 24 hours is incorrect and requires intervention. Dating, rotating sites, and ID checks are correct.
An adult client had an abdominal hysterectomy this morning. Meperidine HCl (Demerol) 75 mg IM q3-4h PRN for pain is ordered. At 9:00 P.M., she complains of lower abdominal pain. She was last medicated at 5:45 P.M. What is the most appropriate initial action for the nurse to take?
- A. Offer her a bed pan and a back rub
- B. Reposition her
- C. Administer meperidine HCl 75 mg IM
- D. Encourage her to perform relaxation and breathing exercises
Correct Answer: C
Rationale: The last dose was over 3 hours ago, within the PRN order. Administering meperidine is appropriate for pain relief.
The elderly client is admitted to the emergency department from a long-term care facility. The client has multiple ecchymotic areas on the body. The client is receiving digoxin, a cardiac glycoside; Lasix, a loop diuretic; Coumadin, an anticoagulant; and Xanax, an antianxiety medication. Which order should the nurse request from the health-care provider?
- A. A STAT serum potassium level.
- B. An order to admit to the hospital for observation.
- C. An order to administer Valium intravenous push.
- D. A STAT international normalized ratio (INR).
Correct Answer: D
Rationale: Ecchymosis with Coumadin suggests bleeding risk; STAT INR assesses anticoagulation status, guiding reversal if needed. Potassium, admission, or Valium are less urgent.