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While evaluating a patient who has been taking acetaminophen for chronic pain, the nurse notices that the patient’s skin appears yellow. What action should the nurse take in response to this observation?
- A. Suggest the patient to reduce the dosage of the medication.
- B. Check the patient’s capillary glucose level.
- C. Use a pulse oximeter to assess the patient’s oxygen saturation.
- D. Report the observation to the healthcare provider.
Correct Answer: D
Rationale: Yellow skin (jaundice) suggests liver damage, a serious acetaminophen side effect. Reporting to the provider (D) is critical for evaluation. Reducing dosage (A) without consultation is unsafe. Glucose (B) and oxygen saturation (C) are unrelated to jaundice.
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A patient is receiving a secondary infusion of azithromycin 500 mg in 500 mL of normal saline (NS) to be infused over 2 hours. The intravenous (IV) administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion?
Correct Answer: 42
Rationale: Infusion rate: 500 mL / 2 hr = 250 mL/hr. Drops per minute: (250 mL/hr × 10 gtt/mL) / 60 min = 41.67, rounded to 42 gtt/min. This ensures accurate delivery of azithromycin.
A patient with osteoporosis is administered risedronate at 0700 and requests a glass of milk to take with the medication. What should the nurse’s response be?
- A. Advise the patient to only consume water with the medication.
- B. Delay the medication until the patient’s breakfast tray arrives.
- C. Consult with a pharmacist about administering the dose one hour post-meal.
- D. Assign an unlicensed assistive personnel to bring the patient a glass of low-fat milk.
Correct Answer: A
Rationale: This question is identical to Question 1. Risedronate requires plain water on an empty stomach (A) to ensure absorption. Milk (D) reduces efficacy. Delaying for breakfast (B) or post-meal dosing (C) violates guidelines. Note: Duplicate question; consider removing.
An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?
- A. The client underwent a coronary artery bypass procedure in 1995.
- B. The client had a colonoscopy performed for routine screening six months ago.
- C. The client suffered from depression following the death of their spouse in 1999.
- D. The client has been taking digoxin and furosemide daily since 1996.
Correct Answer: D
Rationale: Digoxin and furosemide (D) can cause nausea, vomiting, and anorexia due to toxicity (digoxin) or electrolyte imbalances (furosemide), critical for heart failure management. Past bypass (A), colonoscopy (B), and depression (C) are less relevant to current symptoms.
The nurse is planning care for a client with major depression who is receiving a new prescription for duloxetine. What information is most important for the nurse to obtain?
- A. Family history of mental illness.
- B. Weight change in the last month.
- C. Liver function laboratory results.
- D. Recent use of other antidepressants.
Correct Answer: C
Rationale: Duloxetine is metabolized by the liver, and impaired liver function can increase toxicity risk. Liver function tests (C) are critical before starting. Family history (A), weight changes (B), and other antidepressants (D) are relevant but secondary to liver safety.
The nurse is preparing to administer the anti-ulcer gastrointestinal agent sucralfate to a patient with peptic ulcer disease. What should be included in this patient’s care plan?
- A. Administer sucralfate once daily, preferably at bedtime.
- B. Give sucralfate on an empty stomach.
- C. Monitor for a secondary Candida infection.
- D. Monitor for electrolyte imbalances.
Correct Answer: B
Rationale: Sucralfate forms a protective barrier over ulcers and should be given on an empty stomach (B), 1 hour before meals or at bedtime, for optimal efficacy. Once-daily dosing (A) is incorrect; it’s typically 4 times daily. Candida infection (C) and electrolyte imbalances (D) are not associated with sucralfate.