Nokea
The nurse is caring for a client with newly prescribed sumatriptan. The nurse understands that this medication is intended to treat which condition?
- A. Peripheral artery disease
- B. Accelerated hypertension
- C. Migraine headache
- D. Angina
Correct Answer: C
Rationale: Sumatriptan is a triptan specifically used to treat migraine headaches by constricting blood vessels and reducing inflammation. It is not used for peripheral artery disease, hypertension, or angina.
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The nurse is reviewing laboratory data for a client taking prescribed phenytoin. The client's phenytoin level is 12 mcg/mL (10-20 mcg/mL). Which action should the nurse take next?
- A. Evaluate the client for non-adherence
- B. Instruct the client to skip the next scheduled dose
- C. Assess the client for phenytoin toxicity
- D. Document the result as within normal limits
Correct Answer: D
Rationale: A phenytoin level of 12 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the nurse should document the result as normal. Non-adherence, skipping doses, or toxicity assessment are not indicated.
The nurse is caring for a client with peripheral neuropathy of the lower extremities. Which intervention would be appropriate to prevent injury to the client's feet?
- A. Perform Semmes-Weinstein monofilament test
- B. Review the client's most recent blood glucose level
- C. Obtain a prescription for gabapentin
- D. Teach the client about appropriate footwear
Correct Answer: D
Rationale: Teaching about appropriate footwear prevents injuries in peripheral neuropathy by protecting insensate feet.
A nurse is instructing a client about a newly prescribed medication, phenytoin. Which statements, if made by the client, indicate effective teaching?
- A. If my gums get irritated and large, I can stop this medication.
- B. I will need laboratory work to monitor the medication level.
- C. It is okay for me to increase this medication if I have a seizure.
- D. I should take this medication with low protein foods.
Correct Answer: B
Rationale: Phenytoin requires regular blood level monitoring to ensure therapeutic levels (10-20 mcg/mL). Stopping due to gum hyperplasia, increasing doses without medical advice, or taking with low-protein foods are incorrect.
A nurse is instructing a client about a newly prescribed medication, phenytoin. Which statements, if made by the client, indicate effective teaching?
- A. If my gums get irritated and large, I can stop this medication.
- B. I will need laboratory work to monitor the medication level.
- C. It is okay for me to increase this medication if I have a seizure.
- D. I should take this medication with low protein foods.
Correct Answer: B
Rationale: Phenytoin requires regular blood level monitoring to ensure therapeutic levels (10-20 mcg/mL). Stopping due to gum hyperplasia, increasing doses without medical advice, or taking with low-protein foods are incorrect.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 1 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
Which of the following assessment findings require immediate follow-up?
- A. Neurological assessment findings
- B. Pulse and temperature
- C. Gastrointestinal assessment findings
- D. Influenza vaccination status
- E. Daily smoking habit
- F. Blood pressure and pulse oximetry reading
Correct Answer: A,B
Rationale: Altered mental status, fever, and tachycardia suggest a serious condition like meningitis, requiring immediate follow-up.