Nokea
The nurse is preparing to administer the first dose of the prescribed IVPB antibiotic. Which 2 actions are most appropriate for the nurse to perform prior to initiating the infusion?
- A. Administer a dose of PRN acetaminophen
- B. Ask about the client's medication allergies
- C. Ensure that prescribed blood cultures have been obtained
- D. Ensure that the prescribed echocardiography has been obtained
- E. Reschedule the antibiotic dose until the central venous catheter is in place
Correct Answer: B,C
Rationale: Antibiotic therapy is a critical component of treatment for clients with infective endocarditis (E). Before administering IV
antibiotics, the nurse should first obtain blood cultures to identify the infectious organism. Broad-spectrum antibiotics are
started initially. Targeted antibiotic therapy can be administered once the blood cultures identify the culprit organisms and their
antimicrobial susceptibilities. Before starting any medication, the nurse should ask about the client's medication allergies to
identify contraindications to therapy
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The nurse has reviewed the information from the Laboratory Results. Complete the following sentence/sentences by choosing from the list/lists of options.The nurse should prioritize interventions to treat ------------ due to the risk of ---------------------.
- A. Hyperkalemia
- B. Dysrhythmias
- C. Elevated BUN
- D. Seizures
- E. Hyponatremia
- F. Acute kidney injury
Correct Answer: A,B
Rationale: The client's laboratory results show hyperkalemia (ie, high potassium) and decreased kidney function, seen as elevated BUN and creatinine.
The kidneys balance potassium levels by eliminating excess potassium through urine. Clients with heart failure (HF) are at an increased risk fo
hyperkalemia due to poor kidney perfusion from decreased cardiac output and medication adverse effects. This client's decreased kidney
function and home medications, including lisinopril (ACE inhibitor) and supplemental potassium chloride, all increase the risk of hyperkalemia.
Because potassium is responsible for myocardial cell repolarization, hyper- or hypokalemia may lead to life-threatening dysrhythmias.
Therefore, the nurse should prioritize interventions to treat hyperkalemia due to the risk of dysrhythmias.
I can never get tuberculosis again once I finish treatment
- A. I should take the medications with antacids.
- B. I will notify my health care provider if my urine becomes orange.
- C. I will use additional contraception while taking rifampin
Correct Answer: D
Rationale: Rifampin is often used in the management of both latent and active tuberculosis (TB) but reduces the effectiveness of oral contraceptive
pills. Therefore, the client should be instructed to use additional methods of contraception during treatment and for 1 month following
the completion of treatment (Option 4).
For each finding below, click to specify if the finding is consistent with the disease process of acute upper gastrointestinal bleed or acute lower gastrointestinal bleed. Each finding may support more than one disease process.
- A. Melena
- B. NSAID use
- C. Hematemesis
- D. History of diverticulosis
- E. History of Helicobacter pylori infection
Correct Answer:
Rationale: Upper gastrointestinal (Gl) bleeding can occur in the esophagus (eg, esophageal varices or in the stomach and duodenum
(eg, peptic ulcer). Findings associated with upper GI bleeding include the following:
• Melena (ie, dark, tarry stools) is due to the release of iron (heme) as blood passes through the entire GI tract and
hemoglobin becomes partially digested
• NSAID use increases the risk of peptic ulcer formation by inhibiting cyclooxygenase-1, an enzyme that helps protect the
stomach lining and promote platelet aggregation.
• Hematemesis (ie, vomiting blood) is due to the presence of blood in the upper GI tract (eg, esophagus, stomach,
duodenum); the blood usually has a coffee ground appearance due to digestion by gastric acid
• Helicobacter pylori infection increases gastric secretions, promoting peptic ulcer formation.
Lower Gl bleeding occurs in structures past the duodenum (eg, small and large intestine, rectum, anus) and is commonly
associated with inflammatory (eg, Crohn disease, ulcerative colitis, diverticulosis) or vascular (eg, hemorrhoids) conditions.
Diverticulosis is a condition where diverticula (ie, hollow outpouchings from the intestine) develop, usually in the large
intestine and occasionally in the small intestine. Diverticula weaken the intestinal wall and increase the risk for GI bleeding.
The nurse is caring for the client 4 days after admission. For each finding below, click to specify if the finding indicates that the client's status is improving or concerning.
- A. Client ate 80% of the meals and took a shower today.
- B. Client is seen joining group activities in the day room.
- C. Client states, "I feel more energetic today than I have in many months."
- D. Client is seen handing a personal watch and photo album to another client.
- E. Client reports depression 0/10 and states, "I feel a lot better. I think I know what I need to do now."
Correct Answer:
Rationale: Participation in group activities, increased appetite, and performing self-hygiene (eg, showering) indicate an
improvement in the client's status because the client was previously withdrawn with little interest in interacting with others or
performing self-care (eg, declining breakfast tray, body odor).
During the early phase of therapy with antidepressants (eg, selective serotonin reuptake inhibitors [escitalopram]), the risk of
suicide may increase because clients can become more energized as the depression lifts, enabling them to carry out previous
suicide plans. The nurse should find concerning the client's statements about feeling more energized and "knowing what to
do now," which can indicate that the client has determined a plan for suicide and is at peace knowing the plan.
Giving away meaningful possessions (eg, watch, photo album) is concerning for an impending suicide attempt. The nurse
should ask directly about thoughts of suicide.
The client is newly prescribed aripiprazole for autism spectrum disorder. The nurse is reinforcing teaching to the client's parents. Which statement by the nurse is appropriate?
- A. Abruptly stopping the medication can cause withdrawal symptoms
- B. Aripiprazole will cure your child's autism.
- C. Restlessness is an expected side effect and will eventually subside.
- D. This medication will eliminate your child's self-harm behaviors
Correct Answer: A
Rationale: Aripiprazole, an atypical antipsychotic medication, is used in the treatment of irritability associated with autism spectrum
disorder (ASD), schizophrenia, bipolar disorder, and other mental health disorders. Aripiprazole works as a partial agonist at
the serotonin and dopamine receptor sites. As a result, the medication has a more favorable safety profile (eg, fewer metabolic
effects, lower potential for prolactin release) than other antipsychotics; however, it may be less effective in symptom relief.
Clients taking aripiprazole should be reminded to not abruptly stop taking the medication because it can cause withdrawal
symptoms (eg, anxiety, dizziness, tachycardia, diaphoresis, insomnia, vomiting) and may exacerbate previous symptoms.
These medications should be weaned over time and substituted with an alternate medication under the supervision of a health
care provider