Nokea
The nurse should instruct a client who is taking dexamethasone (Decadron) and furosemide (Lasix) to report:
- A. Excitability.
- B. Muscle weakness.
- C. Diarrhea.
- D. Increased thirst.
Correct Answer: B
Rationale: Muscle weakness is a serious side effect of dexamethasone (steroid-induced myopathy) and furosemide (potassium loss), requiring prompt reporting.
You may also like to solve these questions
Which of the following medications should the nurse anticipate administering in the event of a heparin overdose?
- A. Warfarin sodium (Coumadin).
- B. Protamine sulfate.
- C. Acetylsalicylic acid (ASA).
- D. Atropine sulfate.
Correct Answer: B
Rationale: Protamine sulfate is the antidote for heparin overdose, neutralizing its anticoagulant effects.
The nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis?
- A. A bulging anterior fontanel
- B. An elevated apical heart rate
- C. The presence of protein in the urine
- D. A drop in blood pressure from baseline
Correct Answer: A
Rationale: A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle, which occurs in hydrocephalus. An elevated apical heart rate, proteinuria, and a drop in blood pressure are not specifically related to increasing cerebrospinal fluid in the brain tissue.
Which of the following would be true regarding medication reconciliation? Select all that apply.
- A. Medication reconciliation is a Joint Commission National Patient Safety Goal.
- B. Medication reconciliation is designed to obtain and communicate an accurate list of a client's home medications across the continuum of care.
- C. Only nurses or health care providers can be involved in medication reconciliation.
- D. Medications are considered reconciled if a medication order exists that is therapeutically equivalent to the one prior to admission.
- E. A medication is considered to be any medication ordered by a physician.
Correct Answer: A, B, D
Rationale: Medication reconciliation is a Joint Commission goal to ensure accurate medication lists across care transitions. Equivalent medications are reconciled, but not all staff are limited to nurses/providers, and not all medications are physician-ordered.
After abdominal surgery, a client has an order for meperidine (Demerol) I.M. 100 mg every 3 to 4 hours and acetaminophen (Tylenol) with codeine 30 mg. The client has been taking meperidine every 4 hours for the past 48 hours, but she tells the nurse that the meperidine is no longer lasting 4 hours and she needs to have it every 3 hours. Which of the following nursing actions is most appropriate?
- A. Realizing that the client is developing tolerance to the meperidine, the nurse administers the meperidine every 3 hours.
- B. The nurse urges the client to take the acetaminophen with codeine to prevent addiction to the meperidine.
- C. The nurse requests an order from the physician to change the dose to an equianalgesic dose of morphine.
- D. The nurse encourages the client to do relaxation exercises to provide distraction from the pain.
Correct Answer: C
Rationale: Increasing frequency suggests tolerance; switching to an equianalgesic dose of morphine may provide better pain control without escalating doses.
The nurse is caring for a client who has just undergone a total knee replacement. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage weight-bearing on the affected leg.
- B. Apply ice packs to the surgical site.
- C. Keep the leg in a dependent position.
- D. Limit range-of-motion exercises.
Correct Answer: B
Rationale: Applying ice packs reduces swelling and pain post-knee replacement, promoting recovery.