Nokea
The nurse is caring for a client with atrial fibrillation who receives a prescription for warfarin. The international normalized ratio (INR) is 2.8. Which action should the nurse take?
- A. Obtain another blood sample.
- B. Give the next scheduled dose.
- C. Monitor for signs of bleeding.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: An INR of 2.8 is within the therapeutic range for atrial fibrillation, but monitoring for bleeding is critical as a routine precaution. Repeating the sample, giving the dose, or notifying the provider are less immediate.
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A client with a history of smoking cigarettes for many years arrives at the clinic and expresses a desire to stop smoking. The client receives a prescription for bupropion to reduce nicotine cravings. Which information should the nurse include in the discharge teaching?
- A. Administer each dose with at least 8 ounces of water.
- B. Consume tyramine-free foods while taking the medicine.
- C. Be aware that difficulty sleeping and weight loss may occur.
- D. Notify the healthcare provider if experiencing changes in taste.
Correct Answer: C
Rationale: Bupropion may cause insomnia and weight loss, which are important side effects for the client to understand. Water intake, tyramine-free diets, and taste changes are not primary concerns with bupropion.
A young adult female client who is planning to become pregnant asks the nurse if she can continue taking isotretinoin for cystic acne. Which information is most important for the nurse to provide this client?
- A. Breastfeeding is not recommended while taking this medication.
- B. Do not take multiple vitamins that contain vitamin A while taking this drug.
- C. Baseline liver function results must be obtained during therapy.
- D. Discontinue this medication one month before attempting to conceive.
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, requiring discontinuation at least one month before conception to prevent birth defects. Breastfeeding, vitamin A, and liver monitoring are secondary concerns.
A female client with mild depression reports to the nurse recently starting St. John's wort. Which information provided by the client requires further instruction?
- A. Hard candy can be used for a dry mouth.
- B. Insomnia may occur while taking the medication.
- C. Another form of contraception is not needed.
- D. Sensitivity to the sun can develop.
Correct Answer: C
Rationale: St. John's wort reduces oral contraceptive effectiveness, necessitating additional contraception. Dry mouth relief, insomnia, and photosensitivity are correct understandings.
A client receives a prescription for a secondary infusion of IV erythromycin 1 gram in 200 mL dextrose 5% in water (D5W) to be infused in 90 minutes. The nurse should program the infusion pump to deliver how many mL/hour? (Enter the numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 133
Rationale: Volume = 200 mL, Time = 90 minutes = 1.5 hours. Infusion rate = 200 mL / 1.5 hours = 133.33 mL/hr, rounded to 133 mL/hr.
History and physical
The client is a 75-year-old female who was admitted to the preop area to prepare for pacemaker insertion. She states that she needs this procedure because her heart rate has been very low, she feels tired all the time, and she has fainted once due to low heart rate. She has a history of worsening symptomatic bradycardia and atrial fibrillation controlled by medication. She has been off anticoagulants for four days to prepare for the procedure.
Nurses notes
0700
Laboratory specimens have been drawn and completed during a preadmission visit. After changing clothes and settling into bed, client was placed on continuous monitoring. Admission process completed.
0800
Peripheral IV (PIV) started in right antecubital with 20 gauge catheter. IV fluids of 0.9% sodium chloride started at 50 mL/hr. Cardiac surgeon in to see client and answers questions about the procedure.
0830
Client reports no known allergies. Vancomycin 1 gram in 250 ml 0.9% sodium chloride started at 125 mL/hr as endocarditis prophylaxis.
0840
Awaiting transfer to operating room (OR).
Vancomycin infusing at 125 mL/hr.
0845: The client says, "I don't feel well." Assessment reveals dizziness, headache, burning sensation on extremities, and red color on face and extremities. Blood pressure is 108/46 mmHg. Vancomycin infusion was stopped. The surgeon was notified.
0850: The client has flushing and redness over her entire body with hives developing. She complains of feeling hot and nauseous. Cool cloths were applied to her face and extremities. She is restless in bed. IVF of NS is running.
0900
Heart rate 90 beats/minute, blood pressure 110/60 mm Hg. Surgeon remains at bedside.
0915
Heart rate 60 beats/minute, blood pressure 120/70 mm Hg. Appears more relaxed - not thrashing about bed. Skin color remains red: reports itching
resulting in symptoms of skin color0945
Heart rate 52 beats/minute, blood pressure 128/72 mm Hg. To OR for pacemaker placement.
1100
Returned from OR. Heart rate 64 beats/minute, blood pressure 118/68 mm Hg, temperature 97.4° F(36.3° C) orally. Verbalizes not being able to stop shaking and pounding chest pain. Short of breath. Skin color is dark pink. Headache increasing and has nausea. Surgeon at bedside. Chest x-ray done. Echocardiogram performed.
Orders
0800
Start peripheral IV
Vancomycin 1 gram in 250 mL 0.9% sodium chloride
0845
• Stop vancomycin
The nurse is implementing solutions to provide care.
0855
IV diphenhydramine
The nurse is assessing the client to update the plan of care.Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. "The nurse determines that the client's is experiencing -----------, and the blood pressure changes are the result of-------------------.
- A. Adverse drug reaction
- B. Antibiotic
- C. Syncope
- D. Heart failure
- E. IV infiltration
Correct Answer: A,B
Rationale: The client’s symptoms (dizziness, hives, etc.) indicate an adverse reaction (Red Man Syndrome) to vancomycin, causing hypotension. Both blanks are correctly filled by 'Adverse drug reaction' and 'Antibiotic' (vancomycin).