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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Penicillin V potassium (Pen-Vee-K) 500 mg PO qid is ordered for an adult client. He reports that he took penicillin for the first time two months ago. What should the nurse do?
- A. Be sure that skin testing for a penicillin allergy has been done
- B. Observe for signs of an allergic response
- C. Withhold the penicillin
- D. Notify the physician
Correct Answer: B
Rationale: The client does not have a history of allergic response to penicillin, so there is no need to skin test or withhold the medication. However, allergic responses often occur after the first administration.
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.
The HCP ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with a myocardial infarction. Which statement best explains the rationale for administering this medication to this client?
- A. It will help prevent the development of congestive heart failure.
- B. This medication will help decrease the client's blood pressure.
- C. ACE inhibitors increase the contractility of the heart muscle.
- D. They will help decrease the development of atherosclerosis.
Correct Answer: A
Rationale: ACE inhibitors reduce afterload and prevent ventricular remodeling, lowering CHF risk post-MI, per ACC/AHA guidelines. BP, contractility, or atherosclerosis are secondary.
A 60-year-old client has been hospitalized for deep vein thrombosis. The client is to be discharged on warfarin (Coumadin) 5 mg PO daily. Which statement that the client makes indicates the best understanding of the medication routine?
- A. I will take aspirin for my arthritis.
- B. I love to eat spinach salads.
- C. I will get a blood test next week.
- D. I made an appointment to have my teeth pulled.
Correct Answer: C
Rationale: Warfarin requires regular INR monitoring via blood tests to ensure therapeutic anticoagulation levels.
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).