Nokea
The client is showing ventricular ectopy, and the HCP orders amiodarone (Cordarone) intravenously. Which interventions should the nurse implement? Select all that apply.
- A. Monitor telemetry continuously.
- B. Assess the client's respiratory status.
- C. Evaluate the client's liver function studies.
- D. Confirm the original order with another nurse.
- E. Prepare to defibrillate the client at 200 joules.
Correct Answer: A,B,C
Rationale: Telemetry monitors dysrhythmias, respiratory status tracks amiodarone’s pulmonary toxicity risk, and liver studies monitor hepatotoxicity. Order confirmation is unnecessary, and defibrillation is unrelated.
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An adult client is seen in the clinic, and sulfisoxazole (Gantrisin) is prescribed. Which information is most appropriate for the nurse to include in the teaching?
- A. Limit your fluid intake to four glasses a day.
- B. If it upsets your stomach, try taking it with an antacid.
- C. Avoid going out in the sun while taking this drug.
- D. Take the tablets with orange juice or milk.
Correct Answer: C
Rationale: Sulfisoxazole causes photosensitivity; avoiding sun exposure is critical to prevent skin reactions.
You are caring for a hypertensive client with a new order for captopril (Capoten). Which information should the nurse include in client teaching?
- A. Avoid green leafy vegetables
- B. Restrict fluids to 1000 cc/day
- C. Avoid the use of salt substitutes
- D. Take the medication with meals
Correct Answer: C
Rationale: Avoid the use of salt substitutes. Captopril can cause an accumulation of potassium or hyperkalemia. Clients should avoid the use of salt substitutes, which are generally potassium-based.
The client diagnosed with asthma is prescribed the mast cell inhibitor cromolyn. Which statement by the client indicates the need for further teaching?
- A. I will take two puffs of my inhaler before I exercise.
- B. I will rinse my mouth with water after taking the medication.
- C. After inhaling the medication, I will hold my breath for 10 seconds.
- D. When I start to wheeze, I will use my inhaler immediately.
Correct Answer: D
Rationale: Cromolyn is a prophylactic, not rescue, medication for asthma; using it during wheezing indicates misunderstanding. Pre-exercise use, breath-holding, and rinsing (though less critical) are correct.
A 13-month-old child is admitted to the emergency room with salicylate poisoning. Her mother found her beside the empty bottle of adult aspirin. She says there were 'about 10' aspirin left in the bottle. What manifestations would the nurse most expect to see in the child?
- A. Bradypnea and pallor
- B. Hyperventilation and hyperpyrexia
- C. Subnormal temperature and bleeding
- D. Melena and bradycardia
Correct Answer: B
Rationale: Salicylate poisoning causes metabolic acidosis, leading to hyperventilation, and stimulates the CNS, causing fever (hyperpyrexia).
A nurse is assigned to perform well-child assessments at a day care center. A staff member interrupts the examinations to ask for assistance. They find a crying 3 year-old child on the floor with mouth wide open and gums bleeding. Two unlabeled open bottles lie nearby. The nurse's first action should be
- A. call the poison control center, then 911
- B. administer syrup of Ipecac to induce vomiting
- C. give the child milk to coat her stomach
- D. ask the staff about the contents of the bottles
Correct Answer: D
Rationale: ask the staff about the contents of the bottles. The nurse needs to assess what the child ingested before determining the next action. Once the substance is identified, the poison control center and emergency response team should be called.