Nokea
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.
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A nurse is caring for a client who received 0.9% sodium chloride 1 L over 4 hr instead of over 8 hr as prescribeWhich of the following information should the nurse enter as a complete documentation of the incident?
- A. IV fluid infused over 4 hr instead of the prescribed 8 hr. Client tolerated fluids well, provider notified.
- B. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
- C. 1 L of 0.9% sodium chloride completed at 0900. Client denies shortness of breath.
- D. IV fluid initiated at 0500. Lungs clear to auscultation.
- E. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. This choice clearly states the key information - the type of IV fluid, volume, and duration of infusion.
2. Mentioning that vital signs were stable indicates client's safety was monitored.
3. Notifying the provider is crucial for any deviation from the prescribed treatment plan.
Incorrect Choices:
A. Fails to mention the type of IV fluid or client's vital signs, lacks detail.
C. Although it mentions the completion time, it does not address the deviation or client's tolerance.
D. Provides irrelevant information about the initiation time and lung assessment.
E. Similar to choice B, but lacks mentioning the infusion duration which is critical for documenting the incident.
A nurse administers a dose of metformin to a client instead of the prescribed dose of metoclopramidWhich of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Notify the provider.
- C. Check the client's blood glucose.
- D. Fill out an incident report.
Correct Answer: C
Rationale: The correct answer is C: Check the client's blood glucose. This is the first action the nurse should take because metformin is used to treat diabetes and can lower blood sugar levels. Checking the client's blood glucose will help assess if the client is experiencing hypoglycemia due to the medication error. Reporting the incident to the charge nurse (A) and filling out an incident report (D) are important steps, but assessing the client's immediate condition takes priority. Notifying the provider (B) can be done after ensuring the client's safety. The other options are not relevant to addressing the immediate concern of potential hypoglycemia.
Which of the following laboratory results should the nurse report to the provider?
- A. A client who has a prescription for heparin and an aPTT of 90 seconds (normal range 30-40 sec)
- B. A client who has a prescription for heparin and an aPTT of 65 seconds (normal range 30-40 sec)
- C. A client who has a prescription for warfarin and an INR of 3.0 (normal range 0.8-1.1)
- D. A client who has a prescription for warfarin and an INR of 2.0 (normal range 0.8-1.1)
Correct Answer: A
Rationale: The correct answer is A. An aPTT of 90 seconds is above the normal range of 30-40 sec, indicating the client is at risk for bleeding due to excessive anticoagulation with heparin. This result should be reported to the provider immediately for further evaluation and possible adjustment of the heparin dose to prevent bleeding complications. Choices B, C, and D all fall within the normal range for their respective medications, so they do not require immediate reporting.
A nurse is preparing to administer PO sodium polystyrene sulfonate to a client who has hyperkalemiWhich of the following actions should the nurse plan to take?
- A. Hold the client's other oral medications for 1 hour post-administration.
- B. Inform the client that this medication can turn stool a light tan color.
- C. Keep the client's solution in the refrigerator for up to 72 hours.
- D. Monitor the client for constipation.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client for constipation. Sodium polystyrene sulfonate is a medication used to treat hyperkalemia by binding excess potassium in the intestines for elimination. Constipation is a common side effect, as the medication can cause a decrease in bowel motility. The nurse should monitor the client for signs of constipation, such as abdominal discomfort, decreased frequency of bowel movements, or difficulty passing stools. This is essential to prevent complications such as bowel obstruction. Holding the client's other oral medications, informing about stool color changes, or refrigerating the solution are not relevant actions for administering sodium polystyrene sulfonate.
Which of the following medications puts the client at risk for developing hearing loss?
- A. Rifampin
- B. Ciprofloxacin
- C. Penicillin G
- D. Gentamicin
Correct Answer: D
Rationale: The correct answer is D: Gentamicin. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, leading to hearing loss. It can damage the hair cells in the inner ear, affecting hearing. Rifampin (A), Ciprofloxacin (B), and Penicillin G (C) are not associated with ototoxicity. Gentamicin should be used cautiously to prevent hearing loss.