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1. A nurse is instructing a client on the application of nitroglycerin transdermal patches.
Which of the following statements by the client indicates an understanding of the teaching?
A. "I should apply a patch every 5 minutes if I develop chest pain."
B. "I will take the patch off right after my evening meal."
C. "I will leave the patch off at least 1 day each week."
D. "I should discard the used patch by flushing it down the toilet."
B. "I will take the patch off right after my evening meal."
Clients should remove the patch each evening for a medication free time of 12 to 14 hr before
applying a new patch to avoid developing a tolerance to the medication's effects.
2. A nurse receives a verbal order from the provider to administer morphine five milligrams
every 4 hours subcutaneously for severe pain as needed. The nurse should identify which of
the following entries as the correct format for the medication administration record (MAR)?
A. MSO4 5 mg subcut every 4 hr PRN severe pain
B. Morphine 5 mg subcut every 4 hr PRN severe pain
C. MSO4 5 mg SQ every 4 hr PRN severe pain
D. Morphine 5.0 mg subcutaneously every 4 hr PRN severe pain
,B. Morphine 5 mg subcut every 4 hr PRN severe pain
The nurse should identify this entry as the correct format for the MAR. The medication name
is spelled out and there are not any abbreviations from The Joint Commission's "Do Not Use"
list included in the transcription.
3. A nurse is caring for a client who is taking acetazolamide for chronic open-angle glaucoma.
For which of the following adverse effects should the nurse instruct the client to monitor and
report?
A. Tingling of fingers
B. Constipation
C. Weight gain
D. Oliguria
A. Tingling of fingers
The nurse should instruct the client to report the adverse effect of paresthesia, a tingling
sensation in the extremities, when taking acetazolamide.
4. A nurse administers a dose of metformin to a client instead of the prescribed dose of
metoclopramide. Which 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.
C. Check the client's blood glucose.
, The first action the nurse should take using the nursing process is to assess the client. The
client is at risk for hypoglycemia. The nurse should monitor the client's blood glucose and
provide the client with a snack to reduce the risk for hypoglycemia.
5. A nurse is caring for a client who has cancer and is taking oral morphine and docusate
sodium. The nurse should instruct the client that taking the docusate sodium daily can
minimize which of the following adverse effects of morphine?
A. Constipation
B. Drowsiness
C. Facial flushing
D. Itching
A. Constipation
Constipation is a common adverse effect of morphine that can be minimized by taking
docusate sodium, a stool
softener that promotes easier evacuation of stool by increasing water and fat in the intestine.
6. A nurse is assessing a client's vital signs prior to the administration of PO digoxin. The
client's BP is 144/86 mm Hg, heart rate is 55/min, and respiratory rate is 20/min. The nurse
should withhold the medication and contact the
provider for which of the following findings?
A. Diastolic BP
B. Systolic BP
C. Heart rate
D. Respiratory rate
C. Heart rate