Nokea
When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. Which action should the nurse take?
- A. Administer an oral analgesic and evaluate its effectiveness before applying the new patch.
- B. Apply the new patch in a different location after removing the original patch.
- C. Place the patch on the client's shoulder and leave both patches in place for 12 hours.
- D. Remove the patch and consult with the healthcare provider about the client's pain resolution.
Correct Answer: B
Rationale: Fentanyl transdermal patches should be applied to a different location after removing the original patch to ensure consistent pain management while preventing skin irritation or overdose. Administering an oral analgesic is unnecessary if the client has no pain, leaving both patches risks overdose, and consulting the provider is not immediate unless opioid need is reassessed.
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Before administering the initial dose of sumatriptan succinate to a client with a migraine headache, it is most important to determine if the client's history includes which problem?
- A. Coronary artery disease.
- B. Irritable bowel syndrome.
- C. Seasonal allergic rhinitis.
- D. Type 2 diabetes mellitus.
Correct Answer: A
Rationale: Sumatriptan causes vasoconstriction, which can exacerbate coronary artery disease, making this history critical to assess. IBS, rhinitis, and diabetes are not contraindications.
History and physical
The client is a 26-year-old female with acute appendicitis. She has a 12 year history of type 1 diabetes mellitus and no other significant medical history. The appendectomy was completed without issue, and the client will be admitted to the surgical floor to recover.
Nurses notes
0730
Admitted the client. She is awake and alert. She rates her pain 2 on a 0 to 10 pain scale. Her pulses are equal bilaterally. Heart rate is 76 beats/minute, normal sinus rhythm. Her oxygen saturation is 100% on room air. She has a gauze dressing over her surgical site, which is clean and dry. Her temperature is 98.5° F (37.0° C) orally. She urinated 50 mL upon arrival in the unit and is reporting she
Lab results
Blood glucose 279mg/dl
Orders
Admit to the surgical floor
• Dextrose 5% and 0.9% sodium chloride IV to infuse at 125 mL/hr
Advance diet as tolerated
• Insulin glargine 12 units SUBQ every 24 hours
. Ceftriaxone 2 gram IV piggy back (IVPB) every
24 hours for 3 days, first dose given in surgery
It is 1800, and the client has a scheduled dose of insulin glargine due. The client has a regular diet tray ordered with 60 carbohydrates. The tray has not yet arrived in the room. For each nursing action below, click to specify if the action is indicated, contraindicated or nonessential.Each row must have one option selected.
- A. Give insulin lispro 4 units: Contraindicated
- B. Verify that the client can count carbohydrates: Nonessential
- C. Mix the insulin lispro and insulin glargine in one syringe: Contraindicated
- D. Give insulin glargine 12 units: Indicated
Correct Answer:
Rationale: A: Lispro is contraindicated without meal intake to avoid hypoglycemia. B: Carb counting is nonessential for scheduled glargine. C: Mixing lispro and glargine is contraindicated. D: Glargine is indicated as scheduled.
A client with peptic ulcer disease is scheduled to receive doses of pantoprazole IV and sucralfate PO before breakfast at 0730. The client reports experiencing heartburn when the nurse brings the scheduled medications. Which action should the nurse take?
- A. Hold the dose of IV pantoprazole until the client has finished eating breakfast.
- B. Provide a PRN dose of antacid along with the scheduled medications.
- C. Instruct the client to take the dose of sucralfate PO while eating breakfast.
- D. Administer both of the medications before breakfast as scheduled.
Correct Answer: D
Rationale: Pantoprazole and sucralfate should be administered before breakfast to maximize acid suppression and ulcer protection. Delaying pantoprazole reduces efficacy, antacids interfere with sucralfate absorption, and sucralfate requires an empty stomach.
History and physical
The client is a 75-year-old female who was admitted to the preop area to prepare for pacemaker insertion. She states that she needs this procedure because her heart rate has been very low, she feels tired all the time, and she has fainted once due to low heart rate. She has a history of worsening symptomatic bradycardia and atrial fibrillation controlled by medication. She has been off anticoagulants for four days to prepare for the procedure.
Nurses notes
0700
Laboratory specimens have been drawn and completed during a preadmission visit. After changing clothes and settling into bed, client was placed on continuous monitoring. Admission process completed.
0800
Peripheral IV (PIV) started in right antecubital with 20 gauge catheter. IV fluids of 0.9% sodium chloride started at 50 mL/hr. Cardiac surgeon in to see client and answers questions about the procedure.
0830
Client reports no known allergies. Vancomycin 1 gram in 250 ml 0.9% sodium chloride started at 125 mL/hr as endocarditis prophylaxis.
0840
Awaiting transfer to operating room (OR).
Vancomycin infusing at 125 mL/hr.
0845: The client says, "I don't feel well." Assessment reveals dizziness, headache, burning sensation on extremities, and red color on face and extremities. Blood pressure is 108/46 mmHg. Vancomycin infusion was stopped. The surgeon was notified.
0850: The client has flushing and redness over her entire body with hives developing. She complains of feeling hot and nauseous. Cool cloths were applied to her face and extremities. She is restless in bed. IVF of NS is running.
0900
Heart rate 90 beats/minute, blood pressure 110/60 mm Hg. Surgeon remains at bedside.
0915
Heart rate 60 beats/minute, blood pressure 120/70 mm Hg. Appears more relaxed - not thrashing about bed. Skin color remains red: reports itching
resulting in symptoms of skin color0945
Heart rate 52 beats/minute, blood pressure 128/72 mm Hg. To OR for pacemaker placement.
1100
Returned from OR. Heart rate 64 beats/minute, blood pressure 118/68 mm Hg, temperature 97.4° F(36.3° C) orally. Verbalizes not being able to stop shaking and pounding chest pain. Short of breath. Skin color is dark pink. Headache increasing and has nausea. Surgeon at bedside. Chest x-ray done. Echocardiogram performed..
Orders
0800
Start peripheral IV
Vancomycin 1 gram in 250 mL 0.9% sodium chloride
Flowsheet
0700
Vital Sign
• Temperature 97.6° F (36.4° C) orally
• Heart rate 44 beats/minute
• Respiratory rate 18 breaths/minute
• Blood pressure 136/50 mm Hg
The nurse is preparing the client's plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.
- A. Dosage in safe range
- B. Peripheral IV in large vein
- C. No known allergies
- D. Used for prophylaxis
- E. Blood urea nitrogen 17 mg/dL (6.07 mmol/L)
- F. Potassium 4.4 mEq/L (4.4 mmol/L)
Correct Answer: A,B,C,E
Rationale: A: Safe dosage prevents toxicity. B: Large vein reduces phlebitis risk. C: No allergies avoids reactions. E: Normal BUN indicates renal function for vancomycin excretion. D and F are less directly related to safety.
During a home visit, the nurse assesses a client with Alzheimer's disease who recently started a new prescription for rivastigmine. The caregiver reports that the client seems to be thinking more clearly but is not sleeping well at night. Which action should the nurse take?
- A. Advise the caregiver that the purpose of the medication is to promote sleep, so a change in medication may be needed.
- B. Explain to the caregiver that insomnia is a common and temporary side effect when the medication is first started.
- C. Instruct the caregiver to withhold the medication until the dosage can be decreased to ensure the client's safety.
- D. Notify the healthcare provider that the dosage of the medication may need to be increased to manage the client's insomnia.
Correct Answer: B
Rationale: Insomnia is a common, often temporary side effect of rivastigmine. Explaining this reassures the caregiver. Rivastigmine is for cognition, not sleep, and withholding or increasing the dose is inappropriate without provider guidance.