Nokea
The nurse is observing a client self-administer two medications that are in a crushable pill form through their G tube. Which of the following would indicate a need for further instruction?
- A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
- B. The client states they will remain in the Semi-Fowler's position for 30 minutes following administration of the medications.
- C. The client mixes their medications with their tube-feeding formula.
- D. The client mixes each medication separately in warm water.
Correct Answer: C
Rationale: Medication should not be mixed with tube-feeding formula or other medications. The G-tube should be flushed before, between, and after the medications, and the client should remain in the Semi-Fowler's position for at least 30 minutes after medications are administered.
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What classification of drug is Diltiazem?
- A. Calcium-Channel Blocker
- B. NSAID
- C. ACE Inhibitor
- D. Beta-Blocker
Correct Answer: A
Rationale: Diltiazem is a calcium-channel blocker that is used to treat hypertension.
The school-aged child taking guanfacine for treating ADHD is being seen by the nurse at school. The child is pale, diaphoretic, and feeling dizzy. What should the nurse do first?
- A. Take the child's blood pressure
- B. Obtain a capillary glucose level
- C. Telephone the parent about the child
- D. Put a cool cloth on the child's forehead
Correct Answer: A
Rationale: Guanfacine (Tenex) can cause hypotension, making blood pressure the first assessment priority.
The client has been prescribed clonidine for the unlabeled purpose of easing the discomfort associated with smoking cessation. Which body system should be the nurse's initial focus when completing the client's physical assessment?
- A. Neurological
- B. Cardiovascular
- C. Gastrointestinal
- D. Musculoskeletal
Correct Answer: B
Rationale: Clonidine (Catapres) can cause hypotension and bradycardia, making the cardiovascular system the initial focus.
The LPN is teaching a first-time mother about breastfeeding her newborn. Which statement, if made by the mother, would reflect that the teaching had been successful?
- A. My baby should be having at least 4-6 wet diapers a day until 1 month.
- B. It's nice that breastfed babies eat a bit less than formula fed babies.
- C. My baby should be nursing 8-12 times a day during this period.
- D. I'm a little nervous about my milk coming in tomorrow. I've heard it's uncomfortable.
Correct Answer: C
Rationale: Newborns should be nursing 8-12 times during the newborn period. Until a mother's milk comes in, babies typically have a wet diaper count that corresponds to the number of days since their birth (one wet diaper for a 1-day-old baby, and so on). Once they are getting milk and not colostrum, infants should have 4-6 wet diapers a day. A mother's milk usually comes in 3-4 days after the initial colostrum stage. Breast milk is digested faster than formula, so breastfed babies typically eat more frequently.
The client who is to receive a scheduled dose of digoxin has an irregular apical pulse at 92 bpm and a serum potassium of 3.9 mEq/L. Which nursing documentation reflects the most appropriate action?
- A. Serum potassium level WNL. Digoxin given for rapid apical pulse.
- B. Digoxin withheld because the client's apical heart rate is irregular.
- C. Digoxin withheld to prevent toxicity due to the low potassium level.
- D. HCP informed of irregular heart rate and low serum potassium level.
Correct Answer: A
Rationale: A: A normal serum potassium level is 3.5 to 5.0 mEq/L. Digoxin (Lanoxin), a cardiac glycoside, slows and strengthens the heart. It is used for rate control in clients with atrial fibrillation, which often produces an irregular rhythm. B: Dysrhythmias can occur if digoxin is given when the serum potassium level is low, but the serum potassium level is WNL. Digoxin is used for rate control and would not be withheld due to an irregular HR. C: Although it is important to monitor for digoxin toxicity, the serum potassium level is WNL. D: Withholding digoxin and notifying the HCP are unnecessary; the serum potassium is WNL.