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The nurse is caring for a client with epilepsy who is to receive Dilantin 100 mg IV push. The client has an IV of D51/2NS infusing at 100 mL/hr. When administering the Dilantin, the nurse should first:
- A. Obtain an ambu bag and put it at bedside
- B. Insert a 16 g IV catheter
- C. Flush the IV line with normal saline
- D. Premedicate with phenergan IV push
Correct Answer: C
Rationale: Dilantin is incompatible with dextrose solutions (D51/2NS), causing precipitation. Flushing with normal saline ensures compatibility and prevents complications.
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A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
- A. Reinsert the protruding organ and cover with 4x4s
- B. Cover the wound with a sterile 4x4 and ABD dressing
- C. Cover the wound with a sterile saline-soaked dressing
- D. Apply an abdominal binder and manual pressure to the wound
Correct Answer: C
Rationale: Covering the eviscerated wound with a sterile saline-soaked dressing keeps the protruding organs moist and prevents infection until surgical repair.
The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated with morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opioid analgesics?
- A. Naloxone (Narcan)
- B. Ketorolac (Toradol)
- C. Acetylsalicylic acid (aspirin)
- D. Atropine sulfate (Atropine)
Correct Answer: A
Rationale: Naloxone reverses opioid overdose, critical for managing respiratory depression from morphine.
The nurse is preparing a client for discharge following the removal of a cataract. The nurse should tell the client to:
- A. Take aspirin for discomfort
- B. Avoid bending over to put on his shoes
- C. Remove the eye shield before going to sleep
- D. Continue showering as usual
Correct Answer: B
Rationale: Avoiding bending over prevents increased intraocular pressure post-cataract surgery.
A client with advanced Alzheimer's disease has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication?
- A. Cough
- B. Tremors
- C. Diarrhea
- D. Pitting edema
Correct Answer: B
Rationale: Haloperidol, an antipsychotic, can cause extrapyramidal side effects like tremors, which are common and indicate a neurological side effect.
Which laboratory finding would indicate a 62-year-old male client is at risk for ventricular dysrhythmia?
- A. magnesium 0.8 mmEq/L
- B. potassium 4.2 mmol/L
- C. creatinine 1.3 mg/dL
- D. total calcium 2.8 mmol/L
Correct Answer: A
Rationale: Low magnesium (0.8 mEq/L; normal 1.5-2.5 mEq/L) increases the risk of ventricular dysrhythmias. Other values are within normal ranges.