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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.
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The client admitted with pneumonia is taking Imuran, an immunosuppressive agent. Which question should the nurse ask the client regarding this medication?
- A. Do you know this medication has to be tapered off when discontinued?
- B. Have you been exposed to viral hepatitis B or C recently?
- C. Why are you taking this medication, and how long have you taken it?
- D. Do you have a lot of allergies or sensitivities to different medications?
Correct Answer: C
Rationale: Imuran (azathioprine) use and duration clarify indication (e.g., autoimmune) and infection risk, critical with pneumonia. Tapering, hepatitis, or allergies are less immediate.
Keflex 250 mg PO q6h is ordered for an adult. The nurse notes that the client's history indicates that she has an allergy to penicillin. What is the most appropriate initial action for the nurse?
- A. Notify the physician
- B. Observe the client carefully after giving the medication
- C. Administer the Keflex IV instead of PO
- D. Ask the client to describe the reaction that she had to penicillin
Correct Answer: D
Rationale: There is often a cross-allergy between penicillin and cephalosporins like Keflex. The nurse should first determine the type of reaction to assess if Keflex is safe.
The client is in end-stage renal disease and is receiving sodium polystyrene sulfonate (Kayexalate) via an enema. Which data indicate the medication is effective?
- A. The client has 30 mL/hr of urine output.
- B. The serum phosphorus level has decreased.
- C. The client is in normal sinus rhythm.
- D. The client's serum potassium level is 5 mEq/L.
Correct Answer: D
Rationale: Kayexalate lowers serum potassium in hyperkalemia; a level of 5 mEq/L (normal) indicates effectiveness. Urine, phosphorus, or rhythm are unrelated.
A 2-year-old child who weighs 33 pounds is to receive a total daily dose of 25 mg/kg of a medication. It is to be administered in three evenly divided doses. The label reads 150 mg/mL. How many milliliters will be injected per dose?
- A. 0.5 mL
- B. 0.83 mL
- C. 3.75 mL
- D. 155 mL
Correct Answer: B
Rationale: First, convert 33 pounds to kilograms: 33 ÷ 2.2 = 15 kg. Then, calculate daily dose: 15 × 25 = 375 mg. Divide by 3 doses: 375 ÷ 3 = 125 mg/dose. Finally, calculate volume: 125 ÷ 150 = 0.83 mL.
The client diagnosed with multiple sclerosis (MS) is receiving Lioresal (baclofen), a muscle relaxant. Which information should the nurse teach the client/family?
- A. The importance of tapering off medication when discontinuing medication.
- B. Baclofen may cause diarrhea, so the client should take antidiarrheal medication.
- C. The client should not be allowed to drive alone while taking this medication.
- D. The need for follow-up visits to obtain a monthly white blood cell count.
Correct Answer: A
Rationale: Baclofen requires tapering to prevent withdrawal symptoms, like seizures, per FDA warnings. Diarrhea, driving, or WBC counts are not primary concerns.