Nokea
The client is complaining of nausea, and the nurse administers the antiemetic promethazine (Phenergan), IVP. Which intervention has priority for this client after administering this medication?
- A. Instruct the client to call the nurse before getting out of bed.
- B. Evaluate the effectiveness of the medication.
- C. Assess the client's abdomen and bowel sounds.
- D. Tell the client not to eat or drink for at least one (1) hour.
Correct Answer: A
Rationale: Promethazine causes sedation and orthostatic hypotension; instructing to call before ambulating prevents falls, the priority post-IVP.
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The nurse is preparing to administer 37.5 mg of meperidine (Demerol) IM to a client who is having pain. The medication comes in a 50-mg/mL vial. Which action should the nurse implement?
- A. Notify the pharmacist to bring the correct vial.
- B. Have another nurse verify wastage of medication.
- C. Administer one (1) mL of medication to the client.
- D. Request the HCP to increase the client's dose.
Correct Answer: B
Rationale: Dose: 37.5 mg / 50 mg/mL = 0.75 mL. Wasting 0.25 mL requires verification by another nurse, per narcotic protocols.
The nurse is administering an otic drop to the 45-year-old client. Which procedure should the nurse implement when administering the drops?
- A. Place the drops when pulling the ear down and back.
- B. Place the drops when pulling the ear up and back.
- C. Place the drops in the lower conjunctival sac.
- D. Place the drops in the inner canthus and apply pressure.
Correct Answer: B
Rationale: For adults, pulling the ear up and back straightens the ear canal for otic drops. Down/back is for children, others are for ophthalmic drops.
The nurse is administering digoxin, a cardiac glycoside, to the client with congestive heart failure. Which interventions should the nurse implement? Select all that apply.
- A. Check the apical heart rate for one (1) full minute.
- B. Monitor the client's serum sodium level.
- C. Teach the client how to take his or her radial pulse.
- D. Evaluate the client's serum digoxin level.
- E. Assess the client for buffalo hump and moon face.
Correct Answer: A,C,D
Rationale: Checking apical HR prevents bradycardia, teaching pulse empowers monitoring, and digoxin levels ensure therapeutic range. Sodium or Cushingoid features are irrelevant.
A client is receiving dexamethasone (Decadron) therapy. What should the nurse plan to monitor in this client?
- A. Urine output every 4 hours
- B. Blood glucose levels every 12 hours
- C. Neurological signs every 2 hours
- D. Oxygen saturation every 8 hours
Correct Answer: B
Rationale: The drug Decadron increases gluconeogenesis. This may lead to hyperglycemia. Therefore the blood sugar level and acetone production must be monitored.
A client confides in the RN that a friend has told her the medication she takes for depression, Wellbutrin, was taken off the market because it caused seizures. What is an appropriate response by the nurse?
- A. Ask your friend about the source of this information.'
- B. Omit the next doses until you talk with the doctor.'
- C. There were problems, but the recommended dose is changed.'
- D. Your health care provider knows the best drug for your condition.'
Correct Answer: C
Rationale: Wellbutrin was introduced in the U.S. in 1985 and then withdrawn because of the occurrence of seizures in some patients taking the drug. The drug was reintroduced in 1989 with specific recommendations regarding dose ranges to limit the occurrence of seizures. The risk of seizure appears to be strongly associated with dose.