Nokea
The nurse is caring for a client with a history of asthma who is receiving montelukast (Singulair) 10 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I take my medication at night.
- B. I have a headache sometimes.
- C. I feel sad and hopeless.
- D. I use my albuterol inhaler when I wheeze.
Correct Answer: C
Rationale: Feeling sad and hopeless suggests depression, a rare but serious side effect of montelukast, requiring immediate evaluation. Options A, B, and D are less concerning: nighttime dosing is standard, headaches are nonspecific, and albuterol use is appropriate.
You may also like to solve these questions
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
- A. Lung sounds
- B. Urine output
- C. Level of alertness
- D. Appetite
Correct Answer: C
Rationale: Level of alertness. Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Respiratory rate of 24 breaths/min.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should
- A. place a call to the client's provider for instructions
- B. send him to the emergency room for evaluation
- C. reassure the client's partner that the symptoms are transient
- D. instruct the client's partner to call the provider if his symptoms become worse
Correct Answer: B
Rationale: This client requires immediate evaluation. A delay in treatment could result in further deterioration of his condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest.
An elderly client with a fractured hip is placed in Buck's traction. The primary purpose for Buck's traction for this client is:
- A. To decrease muscle spasms
- B. To prevent the need for surgery
- C. To alleviate the pain associated with the fracture
- D. To prevent bleeding associated with hip fractures
Correct Answer: A
Rationale: Buck's traction immobilizes the hip to reduce muscle spasms, which can worsen pain and misalignment. It does not prevent surgery or bleeding and is not primarily for pain relief.
An adult is admitted with gastroenteritis. The physician has ordered prochlorperazine (Compazine) 10 mg PO tid PRN or prochlorperazine (Compazine) 5 mg suppository every 6 hours PRN and loperamide (Imodium) 2 mg PO PRN. The client has an episode of diarrhea and complains of nausea. What should the nurse administer?
- A. Prochlorperazine (Compazine) PO
- B. Loperamide (Imodium)
- C. Prochlorperazine (Compazine) PO and loperamide (Imodium)
- D. Prochlorperazine (Compazine) via suppository
Correct Answer: C
Rationale: Nausea and diarrhea warrant both prochlorperazine (anti-emetic) and loperamide (anti-diarrheal) orally, addressing both symptoms effectively.