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A client who is receiving pregabalin for fibromyalgia complains of tremors in the hands. Which action should the nurse implement? a. Collect a capillary glucose level.
b. Administer a PRN dose of an antianxiety drug.
c. Notify the healthcare provider.
d. Obtain orthostatic blood pressure readings. - ANSWER-C.
The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?
a. Initiate cardiopulmonary resuscitation (CPR).
b. Prepare to assist with chest tube insertion.
c. Administer a second dose of naloxone.
d. Determine Glasgow coma scale. - ANSWER-A.
A client scheduled to receive an IM dose of corticotropin tells the nurse about feeling swollen and gaining weight. The client no longer wants to take the medication. What action should the nurse take?
a. Distract the client while administering the medication in the deltoid site. b. Hold the dose and document the client's refusal to take the medication.
c. Inform the client that fluid retention indicates the need for an increased dose.
d. Explain the need to reduce salt intake while the medication dose is tapered off. - ANSWER-D.
The nurse is interviewing a client who takes a daily antihypertensive medication. Current blood pressure reading is 124/80 mmHg. Which client statement supports the nursing problem of, "knowledge deficit of medication regimen"?
a. "If I skip a dose of my antihypertensive medication, my blood pressure will go up again."
b. "My blood pressure is normal because the antihypertensive medication is working."
c. "I will save my blood pressure medicine for tomorrow since my blood pressure is good today."
d. I realize high blood pressure can damage my kidneys without my even knowing it is happening." - ANSWER-C
The healthcare provider prescribes vancomycin 500 mg IV every 12 hours for a client with methicillin-resistant staphylococcus aureus (MRSA). Review of the client's laboratory values shows that serum peak and trough levels are within the desired therapeutic range and the serum creatinine level is 4.5 mg/dL. Which action should the nurse implement?
a. Withhold the next scheduled dose and contact the healthcare provider. b. Monitor the laboratory values until all prescribed doses have been given. c. Administer the next dose and flag the results for the healthcare provider. d. Insert a second IV catheter for the administration of emergency IV fluids. - ANSWER-A.
After taking orlistat for one week, a female client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. Which action should the nurse take? a. Instruct the client to increase her intake of saturated fats over the next week. b. Obtain a stool specimen to evaluate for occult blood and fat content.
c. Ask the client to describe her dietary intake history for the last several days. d. Advise the client to stop taking the drug and contact her healthcare provider. - ANSWER-C.
6. A client receiving a heparin sodium infusion develops hemoptysis. The nurse reviews the client's
laboratory values to include hemoglobin 8 g/dL and platelet count of 50,000/mm3. Vital signs are: oxygen saturation 92% on 50% venturi mask, heart rate 130 beats/minute, respiration 32 breaths/minute, and blood pressure 76/50mmHg. Which intervention should the nurse implement first?
a. Obtain consent for a blood transfusion.
b. Stop the heparin sodium infusion.
c. Titrate Venturi mask oxygen to 60%.
d. Administer protamine sulfate. - ANSWER-B.
The nurse is teaching a client with coronary artery disease about a newly prescribed medication, atorvastatin. The client plans to take the medication in the morning with breakfast. Which food choices are best for the nurse to recommend that the client should include with the meal? (select all that apply) a. Whole milk.
b. Low fat yogurt.
c. Oatmeal.
d. Sliced grapefruit.
e. Whole banana. - ANSWER-C, E
A client received succinylcholine, a depolarizing neuromuscular blocking agent during surgery. Which assessment finding is most important for the nurse to report to the surgeon? a. Observable skin flushing. b. Ventricular tachycardia
c. Neck and shoulder pain
d. Blood pressure 114/72 mm/Hg - ANSWER-B.
A client, who has a myocardial infarction last year, has a daily prescription for aspirin 325 mg by mouth. Which assessment finding should alert the nurse to withhold the medication? a. Low prothrombin time.
b. High white blood cell count.
c. Oral temperature of 97.9 F.
d. Low platelet count. - ANSWER-D.
A nurse administered a second dose of an opioid containing codeine and acetaminophen to a client fifteen minutes after a first dose was administered by another nurse, because the first dose was not documented in the medication record. Which intervention is most important for the nurse to implement?
a. Assess the client's pain on a 10 point scale.
b. Obtain a serum liver enzyme panel.
c. Complete a medication error form.
d. Evaluate the client's vital signs. - ANSWER-D.
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