Nokea
Which nursing intervention is most important when caring for a client receiving aspirin 600mg po QID?
- A. Monitor temperature q4h
- B. Use 10-point pain scale to assess pain
- C. Assess for dyspepsia and nausea
- D. Check stool for occult blood
Correct Answer: D
Rationale: The correct answer is to check the stool for occult blood when caring for a client receiving aspirin 600mg po QID. Aspirin can lead to gastrointestinal bleeding, and checking for occult blood in the stool is essential to monitor for this serious adverse effect. Monitoring temperature, assessing pain, and checking for dyspepsia and nausea are important interventions but not as critical as monitoring for gastrointestinal bleeding when a client is receiving aspirin.
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A client with a diagnosis of depression is prescribed escitalopram. Which statement by the client indicates the need for further teaching?
- A. I should take this medication in the morning with food.
- B. This medication may take 1 to 4 weeks to notice improvement in symptoms.
- C. I can stop taking this medication once I feel better.
- D. This medication might make me feel drowsy.
Correct Answer: C
Rationale: It is crucial for clients to understand that they should not discontinue escitalopram abruptly, even if they start feeling better. Stopping the medication suddenly can lead to withdrawal symptoms or a relapse of depression. It is essential to complete the full course of treatment as prescribed by the healthcare provider to ensure the best outcomes and prevent potential complications.
An older adult with iron deficiency anemia is being discharged with iron supplements, which information should the nurse include in the discharge?
- A. Take the tablet with a daily multivitamin
- B. Crush the tablet and mix it with pudding
- C. Bedtime is the best time to take the tablet
- D. Wait 2 hours after meals to take the tablet
Correct Answer: D
Rationale: The correct answer is to wait 2 hours after meals before taking the iron tablet. This is important to ensure better absorption and efficacy of the iron supplement. Taking the tablet with a daily multivitamin (Choice A) may interfere with iron absorption due to interactions with other minerals. Crushing the tablet and mixing it with pudding (Choice B) can alter the effectiveness of the medication. While bedtime (Choice C) may be convenient, waiting after meals is crucial for optimal iron absorption.
The practical nurse administers lactulose to a client. Which client outcome would indicate a therapeutic response?
- A. An increase in urine output
- B. Two to three soft stools per day
- C. Absence of nausea
- D. Decreased serum potassium
Correct Answer: B
Rationale: Lactulose is a type of laxative that works by preventing the absorption of ammonia in the colon, leading to increased water absorption in the stool and softening of the stool. The therapeutic response to lactulose is indicated by the passage of two to three soft stools per day, showing that the medication is effectively promoting bowel movements.
A client with chronic heart failure is prescribed spironolactone. The nurse should monitor for which potential side effect?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hypernatremia
- D. Hyponatremia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. Spironolactone is a potassium-sparing diuretic that can lead to an excess of potassium in the body, resulting in hyperkalemia. This side effect is important to monitor in clients taking spironolactone, especially those with chronic heart failure, as hyperkalemia can lead to serious cardiac complications.
A postoperative client has a prescription for ketorolac 30mg IV q6h. Which response demonstrates that therapeutic levels of the medication have been achieved?
- A. Observe wound drainage for a change in appearance
- B. Assess the client's calves for inflammation
- C. Perform a pain assessment using a numeric scale
- D. Measure the client's intake and output
Correct Answer: C
Rationale: The correct response is to perform a pain assessment using a numeric scale. Ketorolac is an NSAID prescribed for pain relief. Monitoring pain levels is crucial to evaluate the therapeutic effectiveness of the medication. Pain assessment helps determine if the medication is providing adequate pain relief, indicating that therapeutic levels have been achieved.