Nokea
The client is diagnosed with essential hypertension and is receiving a calcium channel blocker. Which assessment data would warrant the nurse holding the client's medication?
- A. The client's oral temperature is 102°F.
- B. The client complains of a dry, nonproductive cough.
- C. The client's blood pressure reading is 106/76.
- D. The client complains of being dizzy when getting out of bed.
Correct Answer: D
Rationale: Dizziness on standing suggests orthostatic hypotension, a calcium channel blocker side effect, warranting holding the dose to prevent falls. Fever, cough, or BP are less critical.
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The client on bedrest is receiving enoxaparin (Lovenox), a low molecular weight heparin. Which anatomical site is recommended for administering this medication?
- A. The abdominal wall one (1) inch away from the umbilicus.
- B. The vastus lateralis with a 23-gauge needle.
- C. In the deltoid area subcutaneously.
- D. In the anterolateral abdomen.
Correct Answer: D
Rationale: Enoxaparin is injected subcutaneously in the anterolateral abdomen for optimal absorption and minimal bruising, per manufacturer guidelines.
A 48-year-old man is in the emergency room. He has crushing substernal pain and is diaphoretic, apprehensive, and ashen gray in color. The cardiac monitor shows runs of premature ventricular contractions. Which drug is most likely to be given to this client?
- A. Lidocaine
- B. Verapamil
- C. Digitalis
- D. Nitroglycerin
Correct Answer: A
Rationale: Lidocaine is used to treat ventricular arrhythmias, such as premature ventricular contractions, in acute coronary syndrome.
The client is admitted to the burn unit and prescribed pantoprazole (Protonix), a proton pump inhibitor (PPI). Which statement best supports the scientific rationale for administering this medication to a client with a severe burn?
- A. This medication will help prevent a stress ulcer.
- B. This medication will help prevent systemic infections.
- C. This medication will provide continuous vasoconstriction.
- D. This medication will stimulate new skin growth.
Correct Answer: A
Rationale: Severe burns increase stress ulcer risk due to gastric acid hypersecretion; PPIs like pantoprazole prevent this. Infection, vasoconstriction, or skin growth are unrelated.
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.
The client is receiving atropine, an anticholinergic, to minimize the side effects of routine medications. Which intervention will help the client tolerate this medication?
- A. Teach the client about orthostatic hypotension.
- B. Instruct the client to eat a low-residue diet.
- C. Encourage the client to chew sugarless gum.
- D. Discuss the importance of daily isometric exercises.
Correct Answer: C
Rationale: Atropine causes dry mouth; sugarless gum stimulates saliva, improving tolerance. Hypotension, diet, or exercises are unrelated.