Nokea
The nurse is developing a teaching plan for the client prescribed nortriptyline. Which self-care aspects should be included to minimize medication side effects and prevent injury? Select all that apply.
- A. Avoid eating processed meats, cheeses, and wines.
- B. Suck on candy or ice chips to keep your mouth moist.
- C. Run water in the bathroom to stimulate urination if needed.
- D. Increase fluid and fiber in the diet to prevent constipation.
- E. Avoid driving until vision is completely clear to prevent injury.
- F. Increase exposure to sunlight to facilitate vitamin D absorption.
Correct Answer: B,C,D,E
Rationale: Nortriptyline (Pamelor) causes dry mouth, urinary retention, constipation, and blurred vision. Sucking on candy, running water to stimulate urination, increasing fluid and fiber, and avoiding driving until vision is clear are appropriate.
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The child weighing 20 kg is to receive ceftriaxone 2 g IVPB q12h and dexamethasone 3 mg IV-push q6h for 4 days to treat Haemophilus influenzae type b meningitis. The drug reference states that the usual dose of ceftriaxone is 100 mg/kg/dose with a maximum daily dose of 4 g. The recommended dose of dexamethasone for treating H. influenzae type b meningitis is 0.15 mg/kg q6h for 2 to 4 days. Based on the medications prescribed and these findings, which conclusion by the nurse is correct?
- A. The dose of ceftriaxone is too high.
- B. The dose of dexamethasone is too low.
- C. Both medications are safe to administer as prescribed.
- D. The ceftriaxone should be given before the dexamethasone.
Correct Answer: C
Rationale: A: The dose for ceftriaxone is correct (100 mg x 20 kg = 2000 mg; 1000 mg = 1 g; 2000 mg = 2 g). B: The dose of dexamethasone is correct (0.15 mg x 20 kg = 3 mg). C: The doses of ceftriaxone (Rocephin) and dexamethasone (Decadron) are at the recommended doses. D: An IV-push medication takes less time to administer than an IV piggyback (IVPB) medication. The dexamethasone should be administered first.
The nurse has completed swaddling the 2-month-old infant, prepared supplies to cannulate the scalp vein for an IV infusion, and cleansed and shaved the hair at the site over the temporal bone. Place the remaining steps in the order that they should be performed by the nurse.
- A. Return in 60 minutes and reswaddle the infant in a mummy restraint.
- B. With an assistant holding the infant's head, insert a scalp vein needle and observe for blood return.
- C. Apply lidocaine/prilocaine cream to the site selected and unswaddle the infant after the cream application.
- D. Cleanse the shaved area with an antiseptic solution.
- E. Remove the mummy restraint after initiating the infusion and comfort the infant.
- F. Initiate the infusion and cover the infusion needle with a gauze dressing.
Correct Answer: C,A,D,B,F,E
Rationale: C: Apply lidocaine/prilocaine (EMLA) cream to the site selected and unswaddle the infant after the cream application. An anesthetic cream will numb the site and help reduce the infant's pain during insertion. The infant does not need to remain swaddled while the cream reaches its therapeutic effectiveness in about an hour. A: Return in 60 minutes and reswaddle the infant in a mummy restraint. It takes about an hour for the lidocaine/prilocaine cream to reach its therapeutic effectiveness. The infant should be reswaddled to minimize movement during insertion. D: Cleanse the shaved area with an antiseptic solution. Cleansing the area with an antiseptic solution will help prevent inadvertent introduction of microorganisms into the vascular system. B: With an assistant holding the infant's head, insert a scalp vein needle and observe for blood return. Movement of the infant's head can result in loss of the vein access or a needle-stick injury to the infant or nurse. F: Initiate the infusion and cover the infusion needle with a gauze dressing. Once the vein has been successfully cannulated, the site can be dressed and IV fluids started. E: Remove the mummy restraint after initiating the infusion and comfort the infant. The mummy restraint is no longer needed after the IV catheter has been successfully inserted into a scalp vein.
The nurse observes that the client being treated with antipsychotics is unsteady while standing and walking and that the client's hands are trembling slightly. What should the nurse do?
- A. Administer a pm dose of the anticholinergic Trihexyphenidyl.
- B. Offer assistance with ambulation back to the client's room for rest.
- C. Insist that the client remain seated. Applying limb restraints if needed.
- D. Call the HCP to report that early signs of tardive dyskinesia are present.
Correct Answer: A
Rationale: The client is experiencing extrapyramidal symptoms (EPS) of pseudoparkinsonism, requiring an antiparkinsonian agent like trihexyphenidyl.
During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis?
- A. Brain
- B. Bone
- C. Liver
- D. Mediastinum
Correct Answer: C
Rationale: Rectal adenocarcinoma commonly metastasizes to the liver via the portal vein and lymphatics, making it the most likely next site.
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.