Nokea
Which laboratory test should the nurse monitor for the client receiving the intravenous steroid Solu-Medrol?
- A. Potassium level.
- B. Sputum culture and sensitivity.
- C. Glucose level.
- D. Arterial blood gases.
Correct Answer: C
Rationale: Solu-Medrol (methylprednisolone) can cause hyperglycemia, requiring glucose monitoring, especially IV. Potassium, sputum, or ABGs are less directly affected.
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The client is receiving atropine, an anticholinergic, to minimize the side effects of routine medications. Which intervention will help the client tolerate this medication?
- A. Teach the client about orthostatic hypotension.
- B. Instruct the client to eat a low-residue diet.
- C. Encourage the client to chew sugarless gum.
- D. Discuss the importance of daily isometric exercises.
Correct Answer: C
Rationale: Atropine causes dry mouth; sugarless gum stimulates saliva, improving tolerance. Hypotension, diet, or exercises are unrelated.
The nurse is monitoring a client receiving a thrombolytic agent, alteplase (Activase tissue plasminogen activator), for treatment of a myocardial infarction. What outcome indicates the client is receiving adequate therapy within the first hours of treatment?
- A. Absence of a dysrhythmia (or arrhythmia)
- B. Blood pressure reduction
- C. Cardiac enzymes are within normal limits
- D. Return of ST segment to baseline on ECG
Correct Answer: D
Rationale: Return of ST segment to baseline on ECG. Improved perfusion should result from this medication, along with the reduction of ST segment elevation.
An adult is receiving Gantrisin 1 g PO qid for a urinary tract infection. Which statement that she makes indicates a need for more teaching?
- A. If I get a rash, I will apply calamine lotion.
- B. I will take my pills with a full glass of water.
- C. I will take all the pills even if I feel better.
- D. I will stay out of the sun while I am taking the pills.
Correct Answer: A
Rationale: A rash may indicate an adverse reaction to Gantrisin, requiring physician consultation, not self-treatment with calamine lotion.
A client is scheduled for an intravenous pyelogram (IVP). After the contrast material is injected, which of the following client reactions should be reported immediately?
- A. Feeling warm
- B. Face flushing
- C. Salty taste
- D. Hives
Correct Answer: D
Rationale: Hives. This is a sign of anaphylaxis and should be reported immediately. The other reactions are considered normal and the client should be informed that they may occur.
The client received Narcan, a narcotic antagonist, following a colonoscopy. Which action by the nurse has the highest priority?
- A. Document the occurrence in the nurse's notes.
- B. Prepare to administer narcotic medication IV.
- C. Administer oxygen via nasal cannula.
- D. Assess the client every 15 to 30 minutes.
Correct Answer: D
Rationale: Narcan reverses opioids but has a short half-life; frequent assessment (15–30 min) monitors for re-sedation or respiratory depression, the priority.