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The client with MS is prescribed baclofen. Which information is most important for the nurse to evaluate when caring for this client?
- A. Serum baclofen levels
- B. Muscle rigidity and pain
- C. Intake and urine output
- D. Daily weight pattern
Correct Answer: B
Rationale: A: There is no serum baclofen level. B: Baclofen (Lioresal) is used primarily to treat spasticity in MS and spinal cord injuries. The nurse should assess for muscle rigidity, movement, and pain to evaluate medication effectiveness. C: Although baclofen can cause urinary urgency, this is not the most important information. D: Baclofen use is not associated with weight.
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The nurse is assessing the 13-year-old who has been taking somatropin recombinant. Which findings should the nurse report to an HCP?
- A. Erythematous palmar rash
- B. Blood pressure of 122/74 mm Hg
- C. Random blood glucose of 158 mg/dL
- D. X-ray report noting epiphyseal closure
Correct Answer: D
Rationale: A: Erythematous palmar rash is not associated with the use of GH. B: BP of 122/74 in a 13-year-old is considered normal. C: Although GH use may be associated with blood glucose changes, a random blood glucose of 158 mg/dL is normal. D: Somatropin (Genotropin) recombinant is an injectable GH indicated for children with a deficiency of the hormone. It cannot be given once the epiphyses have closed. The nurse should notify the HCP.
The nurse is assessing the client. Which findings indicate that the client may be experiencing physical changes from long-term use of prednisone? Select all that apply.
- A. Weight gain
- B. Increased muscle mass
- C. Fragile skin
- D. Acne vulgaris
- E. Alopecia
Correct Answer: A,C,D
Rationale: A: Weight gain and muscle atrophy are body changes that may occur with long-term glucocorticoid therapy. B: Muscle wasting (not increased muscle mass) is a side effect of prednisone. C: Fragile skin is a possible body change that may occur with long-term glucocorticoid therapy. D: Acne vulgaris may occur with long-term glucocorticoid therapy. E: Hirsutism (not alopecia) is a side effect of prednisone.
The client with tonsillar cancer is receiving filgrastim. Prior to administering the next dose of filgrastim, the nurse notes that the client's absolute neutrophil count is 11,000/mm3. What is the nurse's best action?
- A. Administer filgrastim as prescribed.
- B. Place the client on neutropenic precautions.
- C. Notify the HCP to question giving filgrastim.
- D. Apply gown, gloves, and mask to enter the room.
Correct Answer: C
Rationale: A: Unnecessary doses can cause leukocytosis (WBCs above 100,000/mm3), an adverse effect of filgrastim. B: A normal neutrophil count is greater than 2000/mm3. Neutropenic precautions and protective wear are unnecessary because the filgrastim has been effective in increasing the neutrophil count. C: Filgrastim (Neupogen) is a granulocyte colony-stimulating factor for treatment of neutropenia. Filgrastim is usually discontinued when the absolute neutrophil count reaches 10,000/mm3. D: A high-efficiency particulate air (HEPA) or N95 mask rather than a regular mask should be worn if the client is severely neutropenic (less than 100/mm3).
The nurse is administering Phenobarbital 300 mg IV to the child weighing 18 kg who is in status epilepticus. Which actions should the nurse take to safely administer the medication? Select all that apply.
- A. Administer the phenobarbital over 20 minutes.
- B. Monitor the IV site for signs of extravasation.
- C. Dilute the phenobarbital dose in 10 mL D5W.
- D. Administer the phenobarbital via IV piggyback.
- E. Identify incompatible medications or solutions being infused.
- F. Inject the phenobarbital over 10 minutes in the port closest to the child.
Correct Answer: B,E,F
Rationale: A: This dose of phenobarbital should be administered as an IV-push medication over 10 minutes; administering it over 20 minutes will delay the medication's effects to treat status epilepticus. B: Whenever IV medications are being administered by any route, the site should be evaluated for irritation and extravasation. An extravasation of phenobarbital (Luminal) may cause necrotic tissue changes that necessitate skin grafting. C: Phenobarbital, if diluted, should be mixed with sterile water for injection and not D5W. D: Phenobarbital should be prepared for direct IV administration and not as an IV piggyback because this would delay the child's receiving the medication to terminate the seizure. E: When administering IV medications, identification of medications or solutions that would be incompatible with that medication must occur so that the tubing can be flushed to ensure that crystallization does not occur in the IV tubing. F: Phenobarbital should be administered no faster than 1 mg/kg/min, with a maximum of 30 mg over 1 minute in infants and children.
The client is placed on lorazepam for short-term treatment of anxiety. Which instruction by the nurse is most important with lorazepam use?
- A. Take a second tablet if your anxiety is not being adequately relieved.
- B. If lorazepam is less effective after a few weeks, notify your provider.
- C. Avoid caffeinated foods and beverages, including tea and chocolate.
- D. If you are experiencing drowsiness or dizziness, notify your provider.
Correct Answer: B
Rationale: Lorazepam (Ativan) is a benzodiazepine anxiolytic and sedative-hypnotic medication. If it is less effective after a few weeks, the client may be developing a tolerance to lorazepam, and the HCP should be notified of this.