Nokea
The client in the intensive care department has a nasogastric tube for continuous feedings. The nurse is preparing to administer nifedipine (Procardia XL) via the N/G tube. Which procedure should the nurse follow?
- A. Crush the medication and dissolve it in water.
- B. Administer and flush the N/G tube with cranberry juice.
- C. Give the medication orally with pudding.
- D. Do not administer the medication and notify the HCP.
Correct Answer: D
Rationale: Procardia XL is extended-release and cannot be crushed or given via NG tube; HCP notification is needed for an alternative form.
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The male client comes to the emergency department and reports he stepped on a rusty nail at home about two (2) hours ago. Which question would be most important for the nurse to ask during the admission assessment?
- A. What have you used to clean the puncture site?
- B. Did you bring the nail with you so we can culture it?
- C. Do you remember when you had your last tetanus shot?
- D. Are you able to put any weight on your foot?
Correct Answer: C
Rationale: Tetanus risk is high with puncture wounds; knowing the last tetanus shot guides prophylaxis, the priority per CDC guidelines.
You are caring for a hypertensive client with a new order for captopril (Capoten). Which information should the nurse include in client teaching?
- A. Avoid green leafy vegetables
- B. Restrict fluids to 1000 cc/day
- C. Avoid the use of salt substitutes
- D. Take the medication with meals
Correct Answer: C
Rationale: Avoid the use of salt substitutes. Captopril can cause an accumulation of potassium or hyperkalemia. Clients should avoid the use of salt substitutes, which are generally potassium-based.
The nurse is caring for a 10 year-old client who will be placed on heparin therapy. Which assessment is critical for the nurse to make before initiating therapy?
- A. Vital signs
- B. Weight
- C. Lung sounds
- D. Skin turgor
Correct Answer: B
Rationale: Weight. Check the client's weight because dosage is calculated on the basis of weight.
The 38-year-old client with chronic asthma is prescribed a leukotriene receptor antagonist. Which is the scientific rationale for administering this medication?
- A. This medication is used prophylactically to control asthma.
- B. This medication will cure the client's chronic asthma.
- C. It will stabilize mast cell activities and reduce asthma attacks.
- D. It will cause the bronchioles to dilate and increase the airway.
Correct Answer: A
Rationale: Leukotriene receptor antagonists (e.g., montelukast) are prophylactic, reducing inflammation to control asthma. They don’t cure, stabilize mast cells, or directly dilate bronchioles.
A client is receiving digitalis. The nurse should instruct the client to report which of the following side effects?
- A. Nausea, vomiting, fatigue
- B. Rash, dyspnea, edema
- C. Polyuria, thirst, dry skin
Correct Answer: A
Rationale: Nausea, vomiting, fatigue. Side effects of digitalis toxicity include fatigue, nausea, vomiting, anorexia, and bradycardia. Digitalis inhibits the sodium potassium ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac output.