Nokea
The nurse is administering the loop diuretic furosemide (Lasix) to the client diagnosed with essential hypertension. Which assessment data would warrant the nurse to question administering the medication?
- A. The client's potassium level is 4.2 mEq/L.
- B. The client's urinary output is greater than the intake.
- C. The client has tented skin turgor and dry mucous membranes.
- D. The client has lost two (2) pounds in the last 24 hours.
Correct Answer: C
Rationale: Tented skin turgor and dry membranes indicate dehydration, a contraindication for Lasix, which could worsen fluid loss. Normal potassium, output, or weight loss are expected.
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Ringer's lactate is running at 125 mL/hr. The administration set has 15 drops/mL. What should the drip rate be?
- A. 8 drops/min
- B. 31 drops/min
- C. 50 drops/min
- D. 67 drops/min
Correct Answer: B
Rationale: Divide 125 mL/hr by 60 min/hr and multiply by 15 drops/mL: (125 ÷ 60) × 15 = 31.25, rounded to 31 drops/min.
A 10-month-old child has been diagnosed as having acute otitis media. The pediatrician prescribed amoxicillin suspension. What instructions should the nurse give the child's mother?
- A. When your child's temperature has been normal for two days, discontinue the medicine.
- B. Discard any unused medication.
- C. If your child has symptoms of an ear infection again, start giving her the leftover medication.
- D. Give your child all of the medication in the bottle.
Correct Answer: B
Rationale: The nurse should instruct to discard unused medication to prevent misuse. The full course should be completed, but the bottle is only good for two weeks.
An adult client has pulmonary tuberculosis. He is receiving INH 300 mg PO, ethambutol 1 g PO daily, and streptomycin 1 g IM three times a week. When he comes in for a checkup, he tells the nurse that he hates getting shots and his ears ring most of the time. What advice does the nurse expect will be given to this client?
- A. Take pyridoxine daily.
- B. Expect red-colored urine and feces.
- C. Stop the medications when your cough is gone.
- D. Take streptomycin by mouth instead of by injection.
Correct Answer: B
Rationale: Streptomycin’s ototoxicity may require discontinuation, not pyridoxine (used for INH). Red urine/feces is expected with rifampin, not listed here, but monitoring is key.
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
- A. Pulverize all medications to a powdery condition
- B. Squeeze the tube before using it to break up stagnant liquids
- C. Cleanse the skin around the tube daily with hydrogen peroxide
- D. Flush adequately with water before and after using the tube
Correct Answer: D
Rationale: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only provides for good tube maintenance, it is flushing that moves medications through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.
An elderly client is on an anticholinergic metered dose inhaler (MDI) for chronic obstructive pulmonary disease. The nurse would suggest a spacer to
- A. enhance the administration of the medication
- B. increase client compliance
- C. improve aerosol delivery in clients who are not able to coordinate the MDI
- D. prevent exacerbation of COPD
Correct Answer: C
Rationale: Spacers improve the medication delivery in clients who are unable to coordinate the movements of administering a dose with an MDI.