Nokea
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.
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The nurse is administering a.m. medications. Which medication should the nurse administer first?
- A. The daily digoxin to the client diagnosed with congestive heart failure.
- B. The loop diuretic to the client with a serum potassium level of 3.1 mEq/L.
- C. The mucosal barrier Carafate to the client diagnosed with peptic ulcer disease.
- D. Solu-Medrol IVP to a client diagnosed with chronic lung disease.
Correct Answer: C
Rationale: Carafate (sucralfate) forms a protective barrier and must be given on an empty stomach, 30–60 minutes before other meds, to be effective for PUD.
A child presents to the Emergency Department with documented acetaminophen poisoning. In order to provide counseling and education for the parents, which principle must the nurse understand?
- A. The problem occurs in stages with recovery within 12-24 hours
- B. Hepatic problems may occur and may be life-threatening
- C. Full and rapid recovery can be expected in most children
- D. This poisoning is usually fatal, as no antidote is available
Correct Answer: B
Rationale: Hepatic problems may occur and may be life-threatening. Clinical manifestations associated with acetaminophen poisoning occur in 4 stages. The third stage is hepatic involvement which may last up to 7 days and be permanent. Clients who do not die in the hepatic stage gradually recover.
Which observation, if reported by a client, is most suggestive of an adverse reaction to gentamicin?
- A. A WBC of 8000
- B. Ringing in the ears
- C. Itching
- D. Nasal stuffiness
Correct Answer: B
Rationale: Gentamicin is ototoxic. Ringing in the ears suggests possible damage to the eighth cranial nerve, the auditory nerve. A WBC of 8000 is normal.
An adult is receiving Gantrisin 1 g PO qid for a urinary tract infection. Which statement that she makes indicates a need for more teaching?
- A. If I get a rash, I will apply calamine lotion.
- B. I will take my pills with a full glass of water.
- C. I will take all the pills even if I feel better.
- D. I will stay out of the sun while I am taking the pills.
Correct Answer: A
Rationale: A rash may indicate an adverse reaction to Gantrisin, requiring physician consultation, not self-treatment with calamine lotion.
The nurse is administering an intramuscular (IM) injection to a client. When the nurse aspirates, there is a blood return. What is the most appropriate action for the nurse to take?
- A. Continue to administer the medication
- B. Withdraw the needle and administer in another site
- C. Withdraw the needle, discard the medication, and start over
- D. Change the needle before administering the medication in another site
Correct Answer: C
Rationale: The nurse should not inject medication that has blood in it. Blood may interact with the medication and cause an adverse response.