Nokea
Which is known as the fifth vital sign?
- A. Temperature
- B. Respirations
- C. Pain
- D. Pulse
Correct Answer: C
Rationale: Pain is known as the fifth vital sign.
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Patient education regarding the use of ciprofloxacin-hydrocortisone (Cipro HC otic) ear drops includes:
- A. Fill the canal with the drops with each dose
- B. Some redness and itching around the ear canal is normal
- C. Warm the bottle of ear drops in his or her hand before administering
- D. Cipro HC otic may cause ototoxicity
Correct Answer: C
Rationale: Warming Cipro HC improves comfort; filling or ototoxicity aren't standard advice.
A patient who takes an oral sulfonylurea medication will begin taking fluconazole (Diflucan). The nurse will expect to monitor which lab values in this patient?
- A. Blood urea nitrogen (BUN) and creatinine
- B. Electrolytes
- C. Fluconazole levels
- D. Glucose
Correct Answer: D
Rationale: Fluconazole inhibits CYP450, increasing sulfonylurea levels and hypoglycemia risk; glucose monitoring is key. Patients taking sulfonylurea drugs may have altered serum glucose when taking antifungal medications.
The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if which of the following is documented in the client's history?
- A. Pancreatitis
- B. Diabetes mellitus
- C. Myocardial infarction
- D. Chronic obstructive pulmonary disease
Correct Answer: A
Rationale: Asparaginase (Elspar) is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between administration of the doses. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The conditions noted in options 2, 3, and 4 are not contraindicated with this medication.
A patient has been using sleeping pills every night for the past several months. Now admitted to the hospital, he is prescribed his usual dose of sleeping pill. After administration, the patient continues to be restless and is wide awake. The nurse notifies the health care provider, who prescribes an increased dose. After receiving the new dose, the patient falls asleep. The nurse interprets this as which of the following?
- A. Drug idiosyncrasy
- B. Cumulative drug effect
- C. Drug tolerance
- D. Toxic reactions
Correct Answer: C
Rationale: The patient has developed drug tolerance and has to be administered an increased dosage of the drug to achieve the desired effect. Cumulative drug effect occurs when the body is unable to metabolize and excrete one (normal) dose of a drug before the next dose is given. Drug idiosyncrasy is a term used to describe any unusual or abnormal reaction to a drug. Toxic reactions are caused when blood concentration levels exceed the therapeutic levels of a drug.
A nurse is instructing a client who has a new prescription for Timolol how to insert eye drops. The nurse should instruct the client to press on which of the following areas to prevent systemic absorption of the medication?
- A. Bony orbit
- B. Nasolacrimal duct
- C. Conjunctival sac
- D. Outer canthus
Correct Answer: B
Rationale: Pressing the nasolacrimal duct prevents systemic absorption by blocking drainage into the nasal cavity.