Nokea
The nurse is preparing to give a dose of oral clindamycin (Cleocin) to a patient being treated for a skin infection caused by Staphylococcus aureus. The patient has experienced nausea after several doses. What should the nurse do next?
- A. Administer the next dose when the patient has an empty stomach.
- B. Hold the next dose and contact the patient's provider.
- C. Instruct the patient to take the next dose with a full glass of water.
- D. Request an order for an antacid to give along with the next dose.
Correct Answer: C
Rationale: The correct action for the nurse to take next is to instruct the patient to take the next dose of clindamycin with a full glass of water. This is important to minimize gastrointestinal (GI) irritation such as nausea, vomiting, and stomatitis that the patient has been experiencing. Administering the medication on an empty stomach would likely worsen the GI upset. Holding the next dose and contacting the provider is not necessary at this point unless symptoms persist or worsen. Additionally, requesting an antacid is not indicated as the primary intervention for managing the nausea related to clindamycin.
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After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
- A. I will take this medication with food and plenty of water.
- B. I shall keep my appointment at the infusion center each week.
- C. I'll limit my intake of green leafy vegetables while on this medication.
- D. I must not take this medication if I have an infection or am feeling ill.
Correct Answer: B
Rationale: The correct answer is B. Temsirolimus, also known as Torisel, is administered as a weekly intravenous infusion. This medication blocks protein needed for cell division, inhibiting cell cycle progression. It is not taken orally, so there is no need to take it with food or water. Keeping the weekly infusion center appointment is crucial for the client to receive the prescribed treatment effectively. Choice A is incorrect as temsirolimus is not taken with food or water. Choice C is incorrect because there is no need to limit the intake of green leafy vegetables while on this medication. Choice D is incorrect as having an infection or feeling ill does not prohibit the use of temsirolimus.
A nurse is preparing for intershift report when a nurse's aide pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first?
- A. Calling the physician
- B. Checking the hourly urine output
- C. Checking the IV site for infiltration
- D. Placing the client in a modified Trendelenburg position
Correct Answer: D
Rationale: The client is exhibiting signs of shock, indicated by tachycardia, tachypnea, and hypotension. Placing the client in a modified Trendelenburg position is the initial action to improve venous return, cardiac output, and subsequently increase blood pressure. This position helps redistribute blood flow to vital organs. Calling the physician should follow once immediate intervention has been initiated. Checking the hourly urine output and IV site are important assessments but are secondary to addressing the client's hemodynamic instability and potential for shock.
A client with kidney stones from secondary hyperoxaluria requires medication. Which medication should the nurse anticipate administering?
- A. Phenazopyridine (Pyridium)
- B. Propantheline (Pro-Banthine)
- C. Tolterodine (Detrol LA)
- D. Allopurinol (Zyloprim)
Correct Answer: D
Rationale: The correct answer is D: Allopurinol (Zyloprim). Allopurinol is used to treat kidney stones caused by secondary hyperoxaluria. This medication helps prevent the formation of certain types of kidney stones. Choices A, B, and C are incorrect. Phenazopyridine (Pyridium) is given to clients with urinary tract infections, not for kidney stones. Propantheline (Pro-Banthine) is an anticholinergic medication used for treating certain gastrointestinal conditions, not kidney stones. Tolterodine (Detrol LA) is also an anticholinergic with smooth muscle relaxant properties, primarily used to treat overactive bladder conditions, not kidney stones.
The nurse is administering intravenous fluids to a dehydrated patient. On the second day of care, the patient's weight has increased by 2.25 pounds. The nurse would expect that the patient's fluid intake has
- A. equaled urine output.
- B. exceeded urine output by 1 L.
- C. exceeded urine output by 2.5 L.
- D. exceeded urine output by 3 L.
Correct Answer: B
Rationale: A weight gain of 1 kg, or approximately 2.2 to 2.5 lb, is generally equivalent to 1 liter (L) of fluid retained by the body. In this case, the patient's weight gain of 2.25 pounds suggests an excess fluid retention of approximately 1 liter, indicating that the patient's fluid intake has exceeded urine output by 1 liter. Choices C and D are incorrect as they overestimate the fluid excess based on the patient's weight gain. Choice A is incorrect as it implies an exact balance between fluid intake and urine output, which is not reflected in the given weight increase.
The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8°F (37.6°C). What is the most appropriate action by the nurse?
- A. Administer fluids to increase blood pressure.
- B. Check the white blood cell count.
- C. Monitor the client's temperature.
- D. Connect the client to an electrocardiographic (ECG) monitor.
Correct Answer: C
Rationale: After hemodialysis, it is crucial to monitor the client's temperature because the dialysate is warmed to increase diffusion and prevent hypothermia. The client's temperature might reflect the temperature of the dialysate. There is no need to administer fluids to increase blood pressure as the vital signs are within normal limits. Checking the white blood cell count or connecting the client to an ECG monitor is not necessary based on the information provided.