Nokea
The nurse is caring for a client who has recently started using a PCA pump for pain management. Which of the following statements indicates a need for additional education.
- A. I will continue to report my pain score during assessments.
- B. I understand that there is a maximum dose in an hour that I can receive regardless of how many times I press the button.
- C. I think this new PCA pump is going to finally get rid of my back pain.
- D. I have more control of when and how much medication I receive.
Correct Answer: C
Rationale: The nurse should assess the client for reasonable versus unreasonable expectations of pain management when using a PCA pump. The patient should not expect the pain to go away completely.
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The nurse teaches the client with relapsing-remitting MS about glatiramer. Which information addressed by the client indicates that the nurse's teaching has been effective? Select all that apply.
- A. Keep the medication vial refrigerated until it is to be used.
- B. Glatiramer is given by injection into the subcutaneous tissue.
- C. Rotate injection sites and wait a week before using a site again.
- D. The thigh and abdomen are the best subcutaneous injection sites.
- E. Syringes are washed, air dried, and reused until the needle is dull.
Correct Answer: A,B,C
Rationale: A: Glatiramer is used to delay the progression of MS. To maximize the therapeutic effects of glatiramer, it should be refrigerated and reconstituted correctly. B: Glatiramer is only administered subcutaneously; accidental IV administration must be avoided. C: Injection sites are rotated to prevent skin breakdown or lumps at the injection sites. D: Appropriate subcutaneous injection sites for glatiramer include the thigh, back of the hip, abdomen, and upper arm. E: Used syringes should be placed in a puncture-resistant container for proper disposal. Syringes and needles should not be reused.
The nurse telephones the HCP to request a pm anxiolytic medication order for a hospitalized client having occasional anxiety. Which medication, if prescribed, should the nurse question regarding its effectiveness for prn use?
- A. Buspirone
- B. Lorazepam
- C. Clorazepate
- D. Clonazepam
Correct Answer: A
Rationale: Buspirone (BuSpar) has a 10- to 14-day delay in therapeutic onset, making it unsuitable for prn use.
The client has been on vancomycin for three days. Which of the following symptoms is least concerning?
- A. nausea
- B. headache
- C. vertigo
- D. tinnitus
Correct Answer: B
Rationale: Vancomycin can cause ototoxicity, and tinnitus, vertigo, and nausea are symptoms of this condition. Headache is not typically associated with vancomycin's side effects.
The nurse is preparing to administer morphine sulfate IV to the child in severe pain. The child has an IV infusion of D5W at 50 mL/hr through a PICC. Which intervention is best when administering the medication?
- A. Disconnect the infusion, inject 3 mL of normal saline, and give the morphine sulfate undiluted.
- B. Question the prescribed medication because morphine sulfate cannot be given through a PICC line.
- C. Give the morphine sulfate undiluted into the existing IV tubing's medication port closest to the child.
- D. Dilute the morphine sulfate with 5 mL of NS and give over 5 minutes into the IV tubing port closest to the child.
Correct Answer: D
Rationale: A: Unnecessary IV disconnections increase the risk for infection. Morphine sulfate is compatible with D5W. B: Morphine sulfate can be administered into a PICC access device. C: Administering undiluted morphine sulfate to a child increases the risk of adverse effects. D: The nurse should dilute the morphine sulfate before administration to prevent too-rapid administration and adverse effects. A single dose should be given over 4 to 5 minutes.
The client is receiving multiple medications for treatment of PD. Which signs and symptoms should the nurse recognize as adverse effects of carbidopa-levodopa?
- A. Dystonia and akinesia
- B. Bradykinesia and agitation
- C. Muscle rigidity and cardiac dysrhythmias
- D. Orthostatic hypotension and dry mouth
Correct Answer: D
Rationale: A: Although dystonia is an adverse effect of carbidopa-levodopa, akinesia is a symptom associated with PD. B: Bradykinesia is a symptom associated with PD; agitation is an adverse effect of carbidopa-levodopa. C: Muscle rigidity is a symptom associated with PD; cardiac dysrhythmia is an adverse effect of carbidopa-levodopa. D: Orthostatic hypotension and dry mouth are common adverse effects of carbidopa-levodopa (Sinemet). These can be minimized by slow position changes and sucking on sugarless candy or chewing gum.