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The female nurse realizes she did not administer a medication on time to the client diagnosed with a myocardial infarction. Which action should the nurse implement?
- A. Administer the medication and take no further action.
- B. Notify the director of nurses of the medication error.
- C. Complete a medication error report form.
- D. Report the error to the Peer Review Committee.
Correct Answer: C
Rationale: A medication error requires completing an error report per facility policy to ensure tracking and quality improvement, especially for MI patients.
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An adult client is receiving lithium 600 mg PO tid for the treatment of bipolar disorder. The client should be taught that it is important to have adequate amounts of which substance?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Magnesium
Correct Answer: B
Rationale: Adequate sodium intake is crucial with lithium to prevent toxicity, as low sodium levels increase lithium retention.
A client is receiving erythromycin 500 mg IV every 6 hours to treat a pneumonia. Which of the following is the most common side effect of the medication?
- A. Blurred vision
- B. Nausea and vomiting
- C. Severe headache
- D. Insomnia
Correct Answer: B
Rationale: Nausea and vomiting. Nausea is a common side-effect of erythromycin in both oral and intravenous forms.
The client is complaining of incisional pain. Which intervention should the nurse implement first?
- A. Administer the pain medication STAT.
- B. Determine when the last pain medication was given.
- C. Assess the client's pulse and blood pressure.
- D. Teach the client distraction techniques to address pain.
Correct Answer: B
Rationale: Determining the last dose ensures safe timing and avoids overdose, the first step in pain management per nursing process.
The client diagnosed with epilepsy is being discharged from the hospital with a prescription for phenytoin (Dilantin) by mouth. Which discharge instructions should the nurse discuss with the client?
- A. The client should purchase a self-monitoring Dilantin machine.
- B. The client should see the dentist at least every six (6) months.
- C. The client should never drive when taking this medication.
- D. The client should drink no more than one (1) glass of wine a day.
Correct Answer: B
Rationale: Phenytoin causes gingival hyperplasia; regular dental visits prevent complications. No self-monitoring machines exist, driving bans are not absolute, and alcohol limits are secondary.
The client diagnosed with Parkinson's disease is taking levodopa (L-dopa) and is experiencing an 'on/off' effect. Which action should the nurse take regarding this medication?
- A. Document the occurrence and take no action.
- B. Request the HCP to increase the dose of medication.
- C. Discuss the client's imminent death as a result of this complication.
- D. Explain this is a desired effect of the medication.
Correct Answer: A
Rationale: The on/off effect is a known levodopa issue; documenting monitors progression without immediate action. Increasing dose, death discussions, or calling it desired are incorrect.