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The healthcare provider changes a client's medication prescription from IV to PO administration and doubles the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduces bioavailability. What action should the nurse implement?
- A. Continue administering the medication via the IV route.
- B. Give half the prescribed oral dose until consulting the provider.
- C. Administer the medication orally as prescribed.
- D. Consult with the pharmacist regarding the prescription change.
Correct Answer: D
Rationale: The correct action for the nurse to implement is to consult with the pharmacist regarding the change in prescription. With the high first-pass effect of the medication when given orally, it reduces its bioavailability, meaning a dosage adjustment may be necessary to achieve the desired therapeutic effect. Continuing to administer the medication via the IV route (choice A) is not appropriate as the prescription has been changed to oral administration. Giving half the prescribed oral dose until consulting the provider (choice B) is not recommended without proper guidance, which should come from consulting with the pharmacist. Simply administering the medication orally as prescribed (choice C) without addressing the potential issue of reduced bioavailability may lead to suboptimal treatment outcomes.
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A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?
- A. Find supplies to put a dressing on the client's wrists
- B. Take the client to a room for supervision by staff
- C. Call the healthcare provider to report the client's behavior
- D. Go find a staff member to stay in the room with the client
Correct Answer: B
Rationale: In this situation, the nurse's priority is to ensure the safety and supervision of the client. Moving the client to a room for direct supervision by staff is crucial to prevent further harm and provide immediate support. While cleaning and assessing the client's wrists are important, ensuring ongoing supervision is vital in this scenario. Calling the healthcare provider to report the behavior may be necessary but is not the immediate action required. Finding supplies to dress the client's wrists is important but not as urgent as ensuring constant supervision by staff.
A nurse is preparing to administer an intramuscular (IM) injection to a client. What is the most appropriate site to use for an IM injection in an adult?
- A. Dorsal gluteal muscle
- B. Vastus lateralis muscle
- C. Rectus femoris muscle
- D. Deltoid muscle
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis muscle. The vastus lateralis muscle is a recommended site for IM injections in adults due to its size and accessibility. The dorsal gluteal muscle is not recommended for IM injections in adults due to the proximity to major nerves and blood vessels, increasing the risk of injury. The rectus femoris muscle is not a common site for IM injections in adults. The deltoid muscle is typically used for IM injections in small-volume medications or vaccines, especially in adults.
While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first?
- A. Instruct the client to perform cough and deep breathing exercises
- B. Assess the client's vital signs and respiratory effort
- C. Administer oxygen via nasal cannula according to the PNR protocol
- D. Document assessment findings in the client's medical record
Correct Answer: B
Rationale: The correct first action for the nurse to take in this situation is to assess the client's vital signs and respiratory effort. It is crucial to promptly detect any immediate complications or changes in the client's condition. Instructing cough and deep breathing exercises (choice A) can be considered after further assessment. Administering oxygen (choice C) should be based on assessment findings and healthcare provider's orders. While documenting the findings (choice D) is essential, it should not be the first action when a potential issue with breath sounds is detected.
The nurse is assessing a client with left-sided heart failure who reports nocturia and dyspnea. The nurse identifies pulsus alternans and crackles in all lung fields. Which action is best to include in the client's plan of care?
- A. Begin client education about positive inotropic medications.
- B. Place the client in Trendelenburg position.
- C. Prepare the client for an emergency cardiac catheterization.
- D. Monitor serum Troponin, CK, and CK-MB levels.
Correct Answer: A
Rationale: In the scenario described, the client is exhibiting signs of left-sided heart failure, such as dyspnea, nocturia, pulsus alternans, and crackles in all lung fields. Positive inotropic medications are commonly used in the treatment of heart failure to improve cardiac contractility and output. Therefore, beginning client education about positive inotropic medications is the best action to include in the client's plan of care.
Choice B is incorrect because placing the client in Trendelenburg position is not indicated in the management of left-sided heart failure. Choice C is incorrect as emergency cardiac catheterization is not typically the initial intervention for left-sided heart failure. Choice D is incorrect as monitoring serum Troponin, CK, and CK-MB levels is more pertinent to assessing for myocardial infarction rather than managing heart failure.
The nurse working on a mental health unit is prioritizing nursing care activities due to a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened, and morning medications need to be prepared. Which plan is best for the nurse to implement?
- A. Wake all the clients and instruct them to go to the dining area for medication administration
- B. Explain to the clients that it will be necessary to cooperate until another RN arrives
- C. Ask the PN to administer medications as clients are awakened so both nurses are available
- D. Allow the clients to sleep until a third staff person can assist with unit activities
Correct Answer: C
Rationale: The best plan for the nurse to implement is to ask the PN to administer medications as clients are awakened. This approach ensures that medication administration and client care are efficiently managed despite the staffing shortage. Option A is incorrect as it may disrupt the workflow and create unnecessary chaos. Option B is not the best choice as it does not address the immediate need for medication administration. Option D is not ideal as it delays client care until additional staff arrive, potentially compromising patient safety and timely medication administration.