The client in the intensive care department is receiving 2 mcg/kg/min of dopamine, an inotropic vasopressor. Which intervention should the nurse include in the plan of care?
- A. Monitor the client's blood pressure every two (2) hours.
- B. Assess the client's peripheral pulses every shift.
- C. Use a urometer to assess hourly output.
- D. Ensure the IV tubing is not exposed to the light.
Correct Answer: C
Rationale: Dopamine affects renal perfusion; hourly urine output via urometer monitors efficacy and prevents toxicity. BP, pulses, or light exposure are less critical.
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The client is to receive 3,000 mg of medication daily in a divided dose every eight (8) hours. The medication comes 500 mg per tablet. How many tablets will the nurse administer at each dose?
Correct Answer: 2
Rationale: Daily dose: 3,000 mg / 3 doses (every 8 hr) = 1,000 mg/dose. Tablets: 1,000 mg / 500 mg/tablet = 2 tablets per dose.
An adult received regular insulin at 7:00 A.M. At 10:00 A.M., she is irritable and sweaty, but her skin is cool. What is the most appropriate action for the nurse to take?
- A. Have her lie down for a rest
- B. Give her a cola drink
- C. Give ordered insulin
- D. Encourage exercise
Correct Answer: B
Rationale: Irritability, sweating, and cool skin suggest hypoglycemia. A cola drink provides quick-acting carbohydrates to raise blood sugar.
A child and the family about the medication phenytoin (Dilantin) prescribed for seizure control. Which of the following side effects is most likely to occur?
- A. Vertigo
- B. Drowsiness
- C. Gingival hyperplasia
- D. Vomiting
Correct Answer: C
Rationale: Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized.
The nurse is teaching a parent how to administer oral iron supplements to a 2 year-old child. Which of the following interventions should be included in the teaching?
- A. Stop the medication if the stools become tarry green
- B. Give the medicine with orange juice and through a straw
- C. Add the medicine to a bottle of formula
- D. Administer the iron with your child's meals
Correct Answer: B
Rationale: Give the medicine with orange juice and through a straw. Absorption of iron is facilitated in an environment rich in Vitamin C. Since liquid iron preparation will stain teeth, a straw is preferred.
The client with osteoarthritis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which intervention should the nurse implement?
- A. Time the medication to be given with meals.
- B. Notify the HCP if abdominal striae develop.
- C. Do not administer if oral temperature is greater than 102°F.
- D. Monitor the liver function tests and renal studies.
Correct Answer: A
Rationale: NSAIDs with meals reduce GI irritation, a common side effect. Striae, fever, or lab monitoring are less immediate concerns.
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