Nokea
Which of the following actions should the nurse take when observing infiltration of fluid into the tissue surrounding an IV insertion site?
- A. Flush the IV catheter
- B. Apply pressure to the IV site
- C. Elevate the extremity
- D. Slow the infusion rate
Correct Answer: C
Rationale: The correct answer is C: Elevate the extremity. Elevating the extremity helps to reduce swelling and minimize further infiltration of fluid into the surrounding tissue. By elevating the extremity, gravity assists in draining the fluid away from the IV site. This action helps to prevent tissue damage and potential complications.
Incorrect choices:
A: Flushing the IV catheter will not address the infiltration and may worsen the situation.
B: Applying pressure to the IV site can further damage the tissue and exacerbate the infiltration.
D: Slowing the infusion rate may not prevent further infiltration and does not address the existing issue effectively.
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Which of the following findings is the best indication that 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 sitting comfortably with eyes closed
- D. The client rates pain as 3 on a scale from 0 to 10
Correct Answer: D
Rationale: The correct answer is D because the client rating pain as 3 on a scale from 0 to 10 indicates that the morphine has effectively reduced their pain. This is a direct measure of the drug's efficacy. Choice A is not a specific indicator of pain relief. Choice B could mean the client is tolerating the pain, not necessarily that the medication is effective. Choice C is subjective and doesn't provide concrete evidence of pain relief.
Which of the following actions of sucralfate should the nurse include in the teaching for a client who is to start a new prescription for sucralfate for peptic ulcer disease?
- A. Decreases stomach acid secretion
- B. Neutralizes acids in the stomach
- C. Forms a protective barrier over ulcers
- D. Treats ulcers by eradicating H. pylori
Correct Answer: C
Rationale: The correct answer is C: Forms a protective barrier over ulcers. Sucralfate works by forming a protective barrier over ulcers in the stomach and small intestine, providing a physical barrier to prevent further damage from stomach acid. This action helps promote healing of the ulcers. Choices A, B, and D are incorrect because sucralfate does not decrease stomach acid secretion, neutralize acids in the stomach, or treat ulcers by eradicating H. pylori bacteria. It is important for the nurse to educate the client on the mechanism of action of sucralfate to ensure understanding and adherence to the treatment plan.
Which of the following findings should indicate to the nurse that the ondansetron has been effective?
- A. Client reports a decrease in pain
- B. Client reports a decrease in nausea
- C. Client reports a decrease in coughing
- D. Client reports a decrease in diarrhea
Correct Answer: B
Rationale: The correct answer is B: Client reports a decrease in nausea. Ondansetron is commonly prescribed to treat nausea and vomiting. A decrease in nausea indicates the medication's effectiveness in managing this specific symptom. Choices A, C, and D are incorrect because ondansetron does not directly target pain, coughing, or diarrhea. It is important for the nurse to focus on the primary purpose of the medication and assess the related symptoms to determine its effectiveness.
Which of the following statements should the nurse include in the teaching about the new medication? Select the 2 statements the nurse should include in the teaching.
- A. You should take medication with dairy products
- B. This medication may cause constipation.
- C. It is common to experience headache or blurred vision while taking this medication.
- D. You should avoid the sun while taking this medication.
Correct Answer: B, D
Rationale: The correct answers are B and D. Statement B is important as it informs the patient about a potential side effect (constipation) of the medication, promoting awareness and preparedness. Statement D is crucial as some medications can increase sensitivity to sunlight, leading to adverse reactions like sunburn. Choices A, C, and the remaining options are incorrect as taking medication with dairy products can interfere with absorption, experiencing headache or blurred vision is not common for all medications, and not all medications require sun avoidance.
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.