Nokea
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.
You may also like to solve these questions
Oral terbutaline is prescribed for the client with bronchitis. Which comorbidity most warrants the nurse's close monitoring of the client following administration of terbutaline?
- A. Strabismus
- B. Hypertension
- C. Diabetes insipidus
- D. Hypothyroidism
Correct Answer: B
Rationale: A: Terbutaline should be used with caution in clients with glaucoma (not strabismus). B: The client's history of hypertension warrants the nurse's close monitoring of the client when terbutaline (Brethine) is administered. It should be used with caution in clients with hypertension because it can precipitate a hypertensive episode. C: Terbutaline should be used with caution in clients with DM (not DI). D: Terbutaline should be used with caution in clients with hyperthyroidism (not hypothyroidism).
A pregnant client asks how she can prevent getting Group B Strep. What is the LPN's best response?
- A. You should have your partner wear a condom every time you have intercourse.
- B. You cannot prevent getting Group B Strep, you can only treat it.
- C. You should be extra vigilant about hand-washing, especially in the third trimester.
- D. The Group B Strep vaccine is the only proven way to prevent the disease.
Correct Answer: B
Rationale: Group B Strep lives in the vagina, rectum, and intestines of about 25% of the female population. It is considered normal flora and is not a sexually transmitted disease. The same woman can test positive in one pregnancy and negative in another, which is why testing is done every pregnancy, usually within 5 weeks of expected delivery. If a woman tests positive for Group B Strep, she will be given antibiotics during delivery to greatly reduce the risk of complications for her and her baby.
The home care nurse is observing the child with asthma self-administer a dose of albuterol via a metered-dose inhaler with a spacer. Within a short time, the child begins to wheeze loudly. What should the nurse do?
- A. Reassure the parent that this usually only occurs with the initial dose.
- B. Notify the HCP; wheezing may indicate paradoxical bronchospasms.
- C. Consult with the HCP to have the child's medication dosage increased.
- D. Reassess the technique; eye contact with albuterol can cause wheezing.
Correct Answer: B
Rationale: A: Reassuring the parent is an inappropriate action; the wheezing is not a normal reaction. There is no indication that this is an initial dose. B: The client's wheezing suggests paradoxical bronchospasms, which can occur with excessive use of adrenergic bronchodilators such as albuterol (Proventil). The medication should be withheld and the HCP notified. C: A paradoxical bronchospasm can occur from excessive use, so the dosage should not be increased. D: Contact with the eyes can cause eye irritation, not wheezing.
The 40-year-old client is receiving levothyroxine for treatment of hypothyroidism. Which serum laboratory results should lead the nurse to conclude that the client's dose is adequate?
- A. Thyroid-stimulating hormone and cortisol
- B. Thyroid-stimulating hormone and free T4
- C. Triiodothyronine (T3) and free thyroxine (T4)
- D. White blood cells, glucose, and potassium
Correct Answer: B
Rationale: A: Cortisol levels are used to evaluate adrenal and not thyroid function. B: Restoration of normal laboratory values for TSH and free T4 indicates that the dose of levothyroxine (Synthroid) is therapeutic. C: T3 is used to evaluate the effectiveness of liothyronine and propylthiouracil, used in the treatment of thyroid disorders. D: The WBC count is used to determine if the client has an infection. Evaluation of serum glucose and potassium levels is unrelated to the use of levothyroxine.
Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
- A. open leg fracture
- B. open head injury
- C. stab wound to the chest
- D. traumatic amputation of a thumb
Correct Answer: C
Rationale: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions.