Nokea
The nurse is preparing to administer levofloxacin (Levaquin) 400 mg orally to a client with a urinary tract infection. Which statement by the client requires further teaching by the nurse?
- A. I will need to wear sunscreen if I am outdoors.
- B. I need to finish all the medication, even if my symptoms go away.
- C. I should take my antacid right before my pill so I don't get heartburn.
- D. I need to check my pulse twice daily and call my doctor if I have new-onset irregular heartbeats.
Correct Answer: C
Rationale: Antacids can reduce levofloxacin absorption and should be taken at least 2 hours apart. Other statements are correct.
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A client has orders for a heparin drip with 20,000 units in a 250 mL bag. The heparin must be delivered at 854 units per hour. What rate will the nurse set for the IV?
Correct Answer: 10.7 mL/hr.
Rationale: Concentration: 20,000 units/250 mL = 80 units/mL. Rate: 854 units/hr ÷ 80 units/mL = 10.675 mL/hr, rounded to 10.7 mL/hr.
The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
- A. Pain beneath the cast
- B. Warm toes
- C. Pedal pulses weak and rapid
- D. Paresthesia of the toes
Correct Answer: C
Rationale: Weak and rapid pedal pulses suggest compromised circulation, which requires immediate reporting to prevent complications like compartment syndrome.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with Cushing's disease
- B. The client with diabetes
- C. The client with acromegaly
- D. The client with myxedema
Correct Answer: A
Rationale: Cushing's disease causes immunosuppression, increasing infection risk, warranting a private room.
A client experienced a major burn over 55% of his body 36 hours ago. The client is restless and anxious, and states, 'I am in pain.' There is a physician prescription for intravenous morphine. The nurse's first action would be to:
- A. Administer the morphine
- B. Assess respirations
- C. Assess urine output
- D. Check serum potassium levels
Correct Answer: B
Rationale: Assessing respirations is critical before administering morphine, as opioids can cause respiratory depression, especially in a burn client with potential airway compromise.
A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
- A. Weight gain
- B. Hair loss
- C. Sore throat
- D. Brittle nails
Correct Answer: C
Rationale: Pulmozyme, used to thin mucus in cystic fibrosis, can cause sore throat as a side effect due to irritation from inhalation.