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The nurse is preparing to care for a patient who has myasthenia gravis. The nurse will be alert to symptoms affecting which body system in the patient?
- A. Gastrointestinal (GI) and lower extremity muscles.
- B. Central nervous system (CNS), memory, and cognition.
- C. Respiratory and facial muscles.
- D. Cardiovascular system and postural muscles.
Correct Answer: C
Rationale: The correct answer is C: Respiratory and facial muscles. Myasthenia gravis is an autoimmune disorder that affects the neuromuscular junction, leading to muscle weakness and fatigue. Symptoms commonly affect muscles involved in breathing (respiratory) and facial expressions, such as difficulty swallowing, breathing, speaking, and facial drooping. Monitoring these systems is crucial as respiratory muscle weakness can lead to respiratory failure. Choice A is incorrect because myasthenia gravis does not typically affect gastrointestinal or lower extremity muscles primarily. Choice B is incorrect as the primary symptoms of myasthenia gravis do not involve the central nervous system but rather the neuromuscular junction. Choice D is incorrect as myasthenia gravis does not directly impact the cardiovascular system or postural muscles.
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A patient has been taking Sertraline (Zoloft) 20mg/ml oral concentrate 1ml daily for several weeks and reports being unable to sleep well. What will the nurse do next?
- A. Ask the patient what time of day the medication is taken.
- B. Recommend asking the provider about weekly dosage.
- C. Counsel the patient to take the medication at bedtime.
- D. Suggest that the patient request a lower dose.
Correct Answer: A
Rationale: The correct answer is A: Ask the patient what time of day the medication is taken. This is because insomnia can be a common side effect of sertraline, and taking it at a different time of day may help alleviate this issue. By understanding the timing of the medication intake, the nurse can assess if adjusting the administration time may improve the patient's sleep. Option B is not directly related to addressing the sleep concern. Option C may help but does not address the timing issue. Option D is premature without assessing the current timing.
A nurse is assessing the patient's home medication use. After listening to the patient's list of current medications, the nurse asks what priority query?
- A. Do you take any generic medications?
- B. Do you take over-the-counter medication?
- C. Are these medications safe to take during pregnancy?
- D. Are any of these medications orphan drugs?
Correct Answer: B
Rationale: The correct answer is B: "Do you take over-the-counter medication?" This is the priority query because over-the-counter medications may interact with prescription drugs, leading to adverse effects. It is crucial for the nurse to assess all medications the patient is taking, including over-the-counter ones, to ensure safety and effectiveness of the overall treatment plan.
Choice A is incorrect because whether the medications are generic or brand name does not directly impact safety or interactions. Choice C is incorrect as it assumes pregnancy, which may not be relevant to the patient. Choice D is incorrect as orphan drugs are not commonly used and not a priority in this context.
A 6-year-old was complaining of elbow pain. The nurse will advise the patient to give which pain medication?
- A. Aleve.
- B. Motrin.
- C. Acetaminophen (Tylenol).
- D. Aspirin (Ecotin).
Correct Answer: C
Rationale: The correct answer is C, Acetaminophen (Tylenol). Acetaminophen is the safest pain medication for children due to its low risk of side effects like gastrointestinal irritation or bleeding, which can be more common with Aleve (A), Motrin (B), and Aspirin (D). Aspirin specifically is contraindicated in children due to the risk of Reye's syndrome. Acetaminophen is also preferred because it has antipyretic properties, making it effective for reducing fever in addition to pain relief. Ultimately, Acetaminophen is the best choice for a 6-year-old experiencing elbow pain due to its safety profile and effectiveness in managing pain and fever.
What would be the best source of drug information for a nurse?
- A. Drug Facts and Comparisons.
- B. A nurse drug guide.
- C. A drug package insert.
- D. The Physician's Drug Reference.
Correct Answer: B
Rationale: The correct answer is B: A nurse drug guide. Nurse drug guides are specifically designed to provide concise and relevant drug information tailored for nursing practice. They include essential details such as dosages, administration routes, side effects, and nursing considerations. Drug Facts and Comparisons (A) is more comprehensive and may contain overwhelming information not directly relevant to nursing practice. Drug package inserts (C) are detailed but not user-friendly for quick reference. The Physician's Drug Reference (D) is aimed at physicians, focusing more on diagnosis and treatment rather than nursing care.
A nurse is caring for a newly admitted patient who will receive Digoxin to treat cardiac dysrhythmia. The patient takes hydrochlorothiazide and reports regular use of OTC laxatives. Before administering the first dose of Digoxin, the nurse will review the patient's electrolyte levels with careful attention to which electrolytes?
- A. Calcium and magnesium.
- B. Potassium and chloride.
- C. Potassium and magnesium.
- D. Sodium and calcium.
Correct Answer: C
Rationale: The correct answer is C: Potassium and magnesium. Digoxin can cause toxicity in patients with low potassium or low magnesium levels, which can be exacerbated by the use of hydrochlorothiazide and OTC laxatives. Monitoring potassium and magnesium levels is crucial to prevent adverse effects such as cardiac dysrhythmias. Calcium and magnesium (choice A) are important electrolytes, but potassium is more critical in the context of Digoxin therapy. Potassium and chloride (choice B) are both important electrolytes, but magnesium should also be monitored. Sodium and calcium (choice D) are not the most relevant electrolytes to monitor in this situation.