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Which of the following medications should the nurse plan to administer to a client with myasthenia gravis who is in a cholinergic crisis?
- A. Potassium Iodide
- B. Glucagon
- C. Atropine
- D. Protamine
Correct Answer: C
Rationale: Rationale:
C: Atropine is the correct answer because it is an anticholinergic medication that can counteract the excess acetylcholine causing cholinergic crisis in myasthenia gravis.
Incorrect choices:
A: Potassium Iodide is used for thyroid conditions, not for myasthenia gravis crises.
B: Glucagon is used for hypoglycemia, not for myasthenia gravis crises.
D: Protamine is used to reverse the effects of heparin, not for myasthenia gravis crises.
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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.
Which of the following findings should indicate to the nurse that a client with myasthenia gravis taking neostigmine is experiencing an adverse effect?
- A. Tachycardia
- B. Oliguria
- C. Xerostomia
- D. Miosis
Correct Answer: D
Rationale: The correct answer is D: Miosis. Neostigmine is a cholinesterase inhibitor used to treat myasthenia gravis. Miosis, or excessive constriction of the pupil, is a sign of cholinergic crisis which can occur due to neostigmine overdose. This adverse effect indicates excessive stimulation of the parasympathetic nervous system, leading to symptoms such as increased salivation, bronchoconstriction, and miosis. Tachycardia (A) is not typically associated with neostigmine use, oliguria (B) is not a common adverse effect, and xerostomia (C) is the opposite of the expected effect of increased salivation due to cholinergic stimulation.
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.
How many mL/h should the nurse set the IV infusion pump to deliver half the total volume of lactated Ringer's (4,080 mL) in the first 8 hours?
- A. 200 mL/h
- B. 225 mL/h
- C. 250 mL/h
- D. 255 mL/h
- E. 275 mL/h
Correct Answer: D
Rationale: The correct answer is D: 255 mL/h. To deliver half of 4,080 mL in 8 hours, you need to administer 2,040 mL in 8 hours. To calculate the infusion rate, divide the total volume by the total time: 2,040 mL ÷ 8 hours = 255 mL/h. This rate ensures half of the total volume is infused within the specified time frame.
Choice A (200 mL/h) is too slow, as it would not deliver half the volume in 8 hours. Choices B, C, and E exceed the required rate and would deliver more than half the volume in 8 hours.
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.