Nokea
Which of the following actions is the priority for the nurse to take after inadvertently administering 160 mg of valsartan PO to a client who was scheduled to receive 80 mg?
- A. Evaluate the client for orthostatic hypotension
- B. Monitor the client's urine output
- C. Obtain the client's laboratory results
- D. Check the client for nasal congestion
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client for orthostatic hypotension. After administering a double dose of Valsartan, the priority is to assess the client for potential adverse effects such as a sudden drop in blood pressure, which can lead to orthostatic hypotension. This is crucial to prevent any harm to the client. Monitoring urine output (B) may be important but is not the immediate priority. Obtaining laboratory results (C) would not provide immediate information on the client's current condition. Checking for nasal congestion (D) is irrelevant to the situation.
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Which of the following information should the nurse include in the teaching about medication reconciliation?
- A. The client's provider is required to complete medication reconciliation.
- B. Medication reconciliation at discharge is limited to the medications ordered at the time of discharge.
- C. A transition in care requires the nurse to conduct medication reconciliation.
- D. Medication reconciliation is limited to the names of the medications that the client is currently taking.
Correct Answer: C
Rationale: The correct answer is C: A transition in care requires the nurse to conduct medication reconciliation. This is because medication reconciliation is crucial during transitions of care to ensure safe and accurate medication management. The nurse plays a key role in reconciling medications to prevent errors and ensure continuity of care.
Incorrect choices:
A: The client's provider is required to complete medication reconciliation - Incorrect, as nurses are often responsible for medication reconciliation, not just the provider.
B: Medication reconciliation at discharge is limited to the medications ordered at the time of discharge - Incorrect, as reconciliation should encompass all medications the client is taking.
D: Medication reconciliation is limited to the names of the medications that the client is currently taking - Incorrect, as it should also include dosages, frequencies, and routes of administration.
Which of the following findings should the nurse report to the provider as an adverse effect of gentamicin?
- A. Constipation
- B. Tinnitus
- C. Hypoglycemia
- D. Joint pain
Correct Answer: B
Rationale: The correct answer is B: Tinnitus. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, including tinnitus. Tinnitus is characterized by ringing or buzzing in the ears and can be an early sign of auditory nerve damage. This adverse effect should be reported to the provider promptly to prevent further hearing loss.
A: Constipation is not a typical adverse effect of gentamicin.
C: Hypoglycemia is not a known adverse effect of gentamicin.
D: Joint pain is not commonly associated with gentamicin use.
A nurse is assessing a client 1 hr after administering morphine for pain. The nurse should identify which of the following findings as the best indication that the morphine has been effective?
- A. The client's vital signs are within normal limits.
- B. The client has not requested additional medication.
- C. The client is resting comfortably with eyes closed.
- D. The client rates pain as 3 on a scale from 0 to 10.
Correct Answer: D
Rationale: Correct Answer: D. The client rates pain as 3 on a scale from 0 to 10.
Rationale: Pain assessment is subjective. The client's self-report of pain is the most reliable indicator of pain relief efficacy. A pain rating of 3 indicates that the pain has decreased from the initial level, suggesting that the morphine has been effective in managing the pain.
Summary of Other Choices:
A: The client's vital signs being within normal limits may not directly correlate with pain relief. Vital signs can be influenced by various factors other than pain relief.
B: The client not requesting additional medication does not necessarily indicate effective pain management as some individuals may hesitate to ask for more medication.
C: The client resting comfortably with eyes closed may indicate relaxation but does not specifically confirm pain relief.
E, F, G: No additional choices provided.
A nurse is teaching a client about cyclobenzaprinWhich of the following client statements should indicate to the nurse that the teaching about cyclobenzaprine was effective?
- A. I will have increased saliva production
- B. I will continue taking the medication until the rash disappears
- C. I will taper off the medication before discontinuing it
- D. I will report any urinary incontinence
Correct Answer: C
Rationale: Correct Answer: C. "I will taper off the medication before discontinuing it."
Rationale: Tapering off cyclobenzaprine is important to prevent withdrawal symptoms due to its muscle relaxant properties. Abruptly stopping the medication can lead to adverse effects. This statement indicates understanding of proper medication management.
Incorrect Choices:
A: Increased saliva production is not a common side effect of cyclobenzaprine.
B: Continuing the medication until the rash disappears is not relevant to cyclobenzaprine.
D: Reporting urinary incontinence is important but not specifically related to cyclobenzaprine teaching.
How many mg should the nurse administer per dose to a child weighing 44 lbs if the prescribed dose is 15 mg/kg every 12 hours?
- A. 150 mg
- B. 200 mg
- C. 300 mg
- D. 350 mg
- E. 400 mg
Correct Answer: C
Rationale: To calculate the correct dose, we first convert the child's weight from pounds to kilograms (44 lbs ÷ 2.2 = 20 kg). Then, we multiply the weight by the prescribed dose (20 kg x 15 mg/kg = 300 mg). Therefore, the nurse should administer 300 mg per dose. Choice A is too low, choices B and D are higher than the correct answer, and choice E is significantly higher, exceeding the calculated dose.