Nokea
The client is receiving intravenous vancomycin. Which assessment finding should the nurse report immediately?
- A. Red man syndrome.
- B. Blood pressure of 130/80 mm Hg.
- C. Mild itching at the IV site.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A: Red man syndrome. This is a severe adverse reaction to vancomycin characterized by flushing, rash, hypotension, and tachycardia. It can progress rapidly to anaphylaxis. Immediate reporting is crucial for prompt intervention. Blood pressure of 130/80 mm Hg is within normal range, mild itching at the IV site is common and can be managed topically, and nausea and vomiting are common side effects of vancomycin but are not life-threatening compared to Red man syndrome.
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During a home visit, the nurse should evaluate the adequacy of a client's COPD treatment by assessing for which primary symptom?
- A. Dyspnea
- B. Tachycardia
- C. Unilateral diminished breath sounds
- D. Edema of the ankles
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Dyspnea is a primary symptom of COPD due to impaired airflow. Assessing dyspnea helps determine the effectiveness of COPD treatment. Tachycardia (B) may occur but is not a primary symptom. Unilateral diminished breath sounds (C) suggest other conditions, not COPD. Edema of the ankles (D) is more indicative of heart failure.
What health promotion teaching should prioritize to prevent drug-induced hepatitis?
- A. Finish all prescribed courses of antibiotics, regardless of symptom resolution
- B. Adhere to dosing recommendations of over-the-counter analgesics
- C. Ensure that expired medications are disposed of safely
- D. Ensure that pharmacists regularly review drug regimens for potential interactions
Correct Answer: B
Rationale: The correct answer is B because adhering to dosing recommendations of over-the-counter analgesics can help prevent drug-induced hepatitis by avoiding potential liver damage from excessive doses. Over-the-counter analgesics like acetaminophen can be hepatotoxic if taken in high amounts. Finishing all prescribed courses of antibiotics (A) is important for antibiotic resistance but does not specifically prevent drug-induced hepatitis. Ensuring safe disposal of expired medications (C) is crucial for environmental safety but does not directly prevent drug-induced hepatitis. Having pharmacists review drug regimens for potential interactions (D) is important for overall medication safety but does not specifically address the prevention of drug-induced hepatitis.
Your patient has an order to receive Levothyroxine Sodium 75 mcg daily IV. You have a vial containing 100 mcg available from the pharmacy. According to the package insert, 5 mL of 0.9% sodium chloride is needed to reconstitute. You add the appropriate amount of sodium chloride to the vial. How many mcg of medication are in 1 mL of the vial?
- A. 20 mcg
- B. 15 mcg
- C. 25 mcg
- D. 30 mcg
Correct Answer: A
Rationale: The correct answer is A: 20 mcg. To determine the amount of medication in 1 mL of the vial, you first need to reconstitute the vial with 5 mL of sodium chloride. This will result in a total of 100 mcg of Levothyroxine Sodium in the vial. To find out how much medication is in 1 mL, you divide the total amount by the volume of the vial (100 mcg / 5 mL = 20 mcg/mL). Therefore, there are 20 mcg of medication in 1 mL of the vial.
Choice B, C, and D are incorrect because they do not accurately calculate the amount of medication in 1 mL of the vial based on the given information and the reconstitution process.
A client is being treated with an antidepressant for major depressive disorder. Which statement by the client indicates a need for further teaching?
- A. I know it may take several weeks before I start feeling better.
- B. I should avoid drinking alcohol while taking this medication.
- C. I will stop taking the medication as soon as I feel better.
- D. I should take the medication at the same time every day.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Stopping medication abruptly can lead to withdrawal symptoms and a potential relapse of depressive symptoms.
2. The client should be educated on the importance of completing the full course of treatment.
3. This statement indicates a lack of understanding regarding the need for continued medication adherence.
4. Choices A, B, and D are all appropriate and demonstrate good understanding of antidepressant treatment.
A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). Which laboratory value indicates a therapeutic effect of the medication?
- A. INR of 2.5.
- B. PTT of 45 seconds.
- C. Hemoglobin of 12 g/dL.
- D. Platelet count of 150,000/mm³.
Correct Answer: A
Rationale: The correct answer is A: INR of 2.5. INR (International Normalized Ratio) is used to monitor the effectiveness of warfarin therapy. A target INR range for DVT treatment is typically 2.0-3.0. An INR of 2.5 indicates that the client's blood is clotting within the desired therapeutic range, preventing excessive clotting while avoiding excessive bleeding.
B: PTT measures the effectiveness of heparin, not warfarin.
C: Hemoglobin level and D: Platelet count are not specific indicators of warfarin's therapeutic effect on clotting factors.
In summary, the correct answer A is the most relevant laboratory value for monitoring the therapeutic effect of warfarin in a client with DVT.