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The client, hospitalized with an exacerbation of SLE, is to receive methylprednisolone 20 mg IV q8h. Which intervention should the nurse anticipate being included in the client's plan of care?
- A. Take orthostatic BPs at least twice daily.
- B. Administer a stool softener twice daily.
- C. Premedicate with diphenhydramine.
- D. Check blood glucose before meals and at bedtime.
Correct Answer: D
Rationale: A: Clients receiving systemic corticosteroids are at risk for hypertension, not orthostatic hypotension. B: Constipation is not an adverse effect of corticosteroid therapy. C: Antihistamine medications are not used before administration of corticosteroids. D: Methylprednisolone (Medrol, Solu-Medrol) is a corticosteroid. Therapy with corticosteroids causes hyperglycemia. The blood glucose level should be monitored.
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The nurse observes a colleague about to administer an IM injection to the 12-month-old. Which intervention requires the nurse to intervene?
- A. Prepares to give no more than 2 mL of fluid
- B. Plans to give the injection using a 1-inch needle
- C. Plans to give the injection in the dorsal gluteal site
- D. Plans to give the injection after applying lidocaine/prilocaine cream
Correct Answer: C
Rationale: A: No more than 2 mL of fluid should be injected into a muscle. B: The appropriate needle length for an IM injection for children ages 2 to 12 months is 1 inch and 1% inch for toddlers. C: Use of the dorsal gluteal site is not recommended due to a high risk of nerve damage. D: Use of lidocaine/prilocaine cream (EMLA) to numb the area is suggested when time allows but is not required.
The nurse telephones the HCP to request a pm anxiolytic medication order for a hospitalized client having occasional anxiety. Which medication, if prescribed, should the nurse question regarding its effectiveness for prn use?
- A. Buspirone
- B. Lorazepam
- C. Clorazepate
- D. Clonazepam
Correct Answer: A
Rationale: Buspirone (BuSpar) has a 10- to 14-day delay in therapeutic onset, making it unsuitable for prn use.
The client taking imipramine is preparing for a summer vacation. Which information should the nurse include when planning client education regarding imipramine? Select all that apply.
- A. Drink additional fluids and add extra fiber to the diet
- B. Stop imipramine if experiencing any unpleasant side effects.
- C. Avoid alcohol, which can cause an additive depressant effect.
- D. Request an “as needed†sleeping pill in the event of insomnia.
- E. Wear sunglasses, protective clothing, and sunscreen while outdoors.
Correct Answer: A,C,E
Rationale: TCAs such as imipramine (Tofranil) may cause constipation, CNS depression when combined with alcohol, and photosensitivity. Increasing fluids and fiber, avoiding alcohol, and using sun protection are appropriate.
The 14-year-old who has GERD is receiving lansoprazole. Which response should the nurse expect if lansoprazole is achieving the desired therapeutic effect?
- A. Increased appetite
- B. Increased GI motility
- C. Decreased epigastric pain
- D. Decreased rectal flatulence
Correct Answer: C
Rationale: A: Lansoprazole would not be expected to change appetite. B: Lansoprazole is not a gastric motility agent. C: Lansoprazole (Prevacid) is a PPI of stomach acid secretion. Decreasing the overall pH allows the gastric mucosa to heal. D: Flatulence is not affected.
The LPN is taking care of a client with a documented allergy to Penicillin. After rounds, the PN notices that the client has an order for Cefazolin. Which of the following actions would be the least appropriate?
- A. The LPN clarifies the severity of the Penicillin allergy.
- B. The LPN discusses the order with the care team prior to administering Cefazolin.
- C. The LPN administers all ordered medications except for the Cefazolin.
- D. The LPN monitors the client after a test dose of Cefazolin is administered.
Correct Answer: C
Rationale: The LPN should clarify the order with the care team prior to determining the medication should not be given. Even though the client may have a potential reaction due to the Penicillin allergy, the therapeutic benefits of the antibiotic may outweigh the allergic reaction.