Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical unit. Which information provided by the UAP warrants immediate intervention by the nurse?
- A. The client diagnosed with cancer of the lung has a small amount of blood in the sputum collection cup.
- B. The client diagnosed with chronic emphysema is sitting on the side of the bed and leaning over the bedside table.
- C. The client receiving Procrit, a biologic response modifier, has a T 99.2°F, P 68, R 24, and BP of 198/102.
- D. The client receiving prednisone, a steroid, is complaining of an upset stomach after eating breakfast.
Correct Answer: C
Rationale: Hypertension (198/102) with Procrit (C) suggests a serious side effect, requiring immediate intervention. Hemoptysis (A), tripod position (B), and stomach upset (D) are expected or less urgent.
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Your patient, who is receiving Pyrazinamide, report stiffness and extreme pain in the right big toe. The site is extremely red, swollen, and warm. You notify the physician and as the nurse you anticipated the doctor will order?
- A. Calcium level
- B. Vitamin B6 level
- C. Uric acid level
- D. Amylase level
Correct Answer: C
Rationale: Pyrazinamide can cause hyperuricemia, leading to gout symptoms (pain, redness, swelling in joints like the big toe). The physician will likely order a uric acid level to confirm this side effect.
Select all the medications used to treat pneumonia that are narrowspectrum?
- A. Macrolides
- B. Tamiflu
- C. Fluroquinolones
- D. Penicillins
Correct Answer: A,D
Rationale: Narrow-spectrum antibiotics target specific bacteria. Macrolides and Penicillins are narrow-spectrum, effective against gram-positive bacteria common in pneumonia. Tamiflu is antiviral, and Fluoroquinolones are broad-spectrum.
Which instruction regarding the prescribed medication is most appropriate to tell this client?
- A. Do not take the drug more frequently than prescribed.
- B. Avoid taking the medication before going to sleep.
- C. Drink more fluid throughout the day.
- D. Warm the cough syrup to make it more palatable.
Correct Answer: C
Rationale: Drinking more fluids enhances the expectorant effect of guaifenesin, helping to thin and expel mucus.
The nurse is writing a care plan for a client newly diagnosed with cancer of the larynx. Which problem is the highest priority?
- A. Wound infection.
- B. Hemorrhage.
- C. Respiratory distress.
- D. Knowledge deficit.
Correct Answer: C
Rationale: Respiratory distress (C) is life-threatening post-laryngectomy, a priority. Infection (A), hemorrhage (B), and knowledge deficit (D) are secondary.
A patient with asthma is receiving a nebulizer of Cromolyn. The patient reports a burning sensation in the nose along with a horrible taste in their mouth. As the nurse you will?
- A. Immediately stop the nebulizer
- B. Re-adjust the nebulizer
- C. Call a rapid response because the patient is having a potential anaphylactic reaction to the medication.
- D. Reassure the patient this is a temporary side effect of this medication.
Correct Answer: D
Rationale: Burning sensation and bad taste are common temporary side effects of Cromolyn nebulizer treatment and do not indicate a severe reaction.