Nokea
When providing discharge teaching to a client with asthma, the nurse will warn against the use of which of the following over-the-counter medications?
- A. Cortisone ointments for skin rashes
- B. Aspirin products for pain relief
- C. Cough medications containing guaifenesin
- D. Histamine blockers for gastric distress
Correct Answer: B
Rationale: Aspirin products for pain relief. Aspirin is known to induce asthma attacks. Aspirin can also cause nasal polyps and rhinitis. Warn individuals with asthma about signs and symptoms resulting from complications due to aspirin ingestion.
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A 13-month-old child is admitted to the emergency room with salicylate poisoning. Her mother found her beside the empty bottle of adult aspirin. She says there were 'about 10' aspirin left in the bottle. What manifestations would the nurse most expect to see in the child?
- A. Bradypnea and pallor
- B. Hyperventilation and hyperpyrexia
- C. Subnormal temperature and bleeding
- D. Melena and bradycardia
Correct Answer: B
Rationale: Salicylate poisoning causes metabolic acidosis, leading to hyperventilation, and stimulates the CNS, causing fever (hyperpyrexia).
The nurse is caring for a 10 year-old client who will be placed on heparin therapy. Which assessment is critical for the nurse to make before initiating therapy?
- A. Vital signs
- B. Weight
- C. Lung sounds
- D. Skin turgor
Correct Answer: B
Rationale: Weight. Check the client's weight because dosage is calculated on the basis of weight.
You are caring for a hypertensive client with a new order for captopril (Capoten). Which information should the nurse include in client teaching?
- A. Avoid green leafy vegetables
- B. Restrict fluids to 1000 cc/day
- C. Avoid the use of salt substitutes
- D. Take the medication with meals
Correct Answer: C
Rationale: Avoid the use of salt substitutes. Captopril can cause an accumulation of potassium or hyperkalemia. Clients should avoid the use of salt substitutes, which are generally potassium-based.
A young adult, 20 years old, who is hospitalized for the first time with schizophrenia, is receiving chlorpromazine (Thorazine) 75 mg PO tid. The client is to go home for a weekend pass. Which statement that the client makes indicates a need for nursing intervention?
- A. I won't drink any alcohol this weekend.
- B. It will be good to taste home-cooked food again.
- C. We plan to go dancing.
- D. I'm looking forward to a relaxing weekend at the beach.
Correct Answer: C
Rationale: Chlorpromazine causes orthostatic hypotension and photosensitivity. Dancing may exacerbate hypotension, requiring caution and education.
The client in end-stage renal disease is a Jehovah's Witness. The HCP orders erythropoietin (Epogen), a biologic response modifier, subcutaneously for anemia. Which action should the nurse take?
- A. Question this order because of the client's religion.
- B. Encourage the client to talk to his or her minister.
- C. Administer the medication subcutaneously as ordered.
- D. Obtain the informed consent prior to administering.
Correct Answer: C
Rationale: Epogen is synthetic, not blood-derived, so it’s acceptable for Jehovah’s Witnesses. Administer as ordered; questioning, minister consultation, or consent are unnecessary.