Nokea
The client is complaining of incisional pain. Which intervention should the nurse implement first?
- A. Administer the pain medication STAT.
- B. Determine when the last pain medication was given.
- C. Assess the client's pulse and blood pressure.
- D. Teach the client distraction techniques to address pain.
Correct Answer: B
Rationale: Determining the last dose ensures safe timing and avoids overdose, the first step in pain management per nursing process.
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A 67-year-old client is to be discharged from the hospital. The client is taking digoxin and furosemide daily. Which instruction is most essential for the nurse to give this client?
- A. Take your medicine early in the day.
- B. Be sure to drink orange juice and eat bananas or melons every day.
- C. Avoid foods that are high in sodium.
- D. Drink plenty of milk.
Correct Answer: B
Rationale: Furosemide causes potassium loss; orange juice, bananas, and melons are potassium-rich, preventing hypokalemia.
The client diagnosed with Parkinson's disease is taking levodopa (L-dopa) and is experiencing an 'on/off' effect. Which action should the nurse take regarding this medication?
- A. Document the occurrence and take no action.
- B. Request the HCP to increase the dose of medication.
- C. Discuss the client's imminent death as a result of this complication.
- D. Explain this is a desired effect of the medication.
Correct Answer: A
Rationale: The on/off effect is a known levodopa issue; documenting monitors progression without immediate action. Increasing dose, death discussions, or calling it desired are incorrect.
The client is receiving the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec). When would the nurse question administering this medication?
- A. The client is not receiving potassium supplements.
- B. The client complains of a persistent irritating cough.
- C. The blood pressure for two (2) consecutive readings is 110/70.
- D. The client's urinary output is 400 mL for the last eight (8) hours.
Correct Answer: B
Rationale: A persistent cough is a common ACE inhibitor side effect, warranting discontinuation or HCP evaluation. Potassium, BP, or urine output are less critical.
The female nurse realizes she did not administer a medication on time to the client diagnosed with a myocardial infarction. Which action should the nurse implement?
- A. Administer the medication and take no further action.
- B. Notify the director of nurses of the medication error.
- C. Complete a medication error report form.
- D. Report the error to the Peer Review Committee.
Correct Answer: C
Rationale: A medication error requires completing an error report per facility policy to ensure tracking and quality improvement, especially for MI patients.
A client has bilateral knee pain from osteoarthritis. In addition to taking the prescribed non-steroidal anti-inflammatory drug (NSAID), the nurse should instruct the client to
- A. start a regular exercise program
- B. rest the knees as much as possible to decrease inflammation
- C. avoid foods high in citric acid
- D. keep the legs elevated when sitting
Correct Answer: A
Rationale: start a regular exercise program. A regular exercise program is beneficial in treating osteoarthritis. It can restore self-esteem and improve physical functioning.