WITH VERIFIED CORRECT ANSWERS & DETAILED EXPLANATIONS
(GRADED A+)
A registered nurse (RN) has administered a dose of naloxone intravenously to a
client with intravenous opioid overdose. The licensed practical nurse (LPN)
assigned to assist in monitoring the client ensures that which of the following
equipment is available in the immediate vicinity of the client?
1. Central line insertion kit
2. Resuscitation equipment
3. Nasogastric tube
4. Thoracentesis tray
2. Resuscitation equipment
Rationale:
Naloxone is used to treat respiratory depression. The client who receives
naloxone for suspected opioid overdose should have resuscitation equipment
readily available to support naloxone therapy if it is needed. Other items
that may be needed include oxygen, a mechanical ventilator, and
medications such as vasopressors.
,A nurse is caring for a client who is receiving an intravenous (IV) infusion of an
antineoplastic medication. During the infusion, the client complains of pain at the
insertion site. During an inspection of the site, the nurse notes redness and
swelling and that the rate of infusion of the medication has slowed. The nurse
should take which appropriate action?
1. Notify the registered nurse.
2. Administer pain medication to reduce the discomfort.
3. Apply ice and maintain the infusion rate, as prescribed.
4. Elevate the extremity of the IV site, and slow the infusion.
1. Notify the registered nurse.
Rationale:
When antineoplastic medications (chemotherapeutic agents) are
administered via IV, great care must be taken to prevent the medication
from escaping into the tissues surrounding the injection site, because pain,
tissue damage, and necrosis can result. The nurse monitors for signs of
extravasation, such as redness or swelling at the insertion site and a
decreased infusion rate. If extravasation occurs, the registered nurse needs to
be notified; he or she will then contact the health care provider.
Desmopressin acetate (DDAVP) is prescribed for the treatment of diabetes
insipidus. The nurse monitors the client after medication administration for which
therapeutic response?
,1. Decreased urinary output
2. Decreased blood pressure
3. Decreased peripheral edema
4. Decreased blood glucose level
1. Decreased urinary output
Rationale:
Desmopressin promotes renal conservation of water. The hormone carries out
this action by acting on the collecting ducts of the kidney to increase their
permeability to water, which results in increased water reabsorption. The
therapeutic effect of this medication would be manifested by a decreased
urine output. Options 2, 3, and 4 are unrelated to the effects of this
medication.
The home health care nurse is visiting a client who was recently diagnosed with
type 2 diabetes mellitus. The client is prescribed repaglinide (Prandin) and
metformin (Glucophage) and asks the nurse to explain these medications. The
nurse should reinforce which instructions to the client? Select all that apply.
1. Diarrhea can occur secondary to the metformin.
2. The repaglinide is not taken if a meal is skipped.
3. The repaglinide is taken 30 minutes before eating.
4. Candy or another simple sugar is carried and used to treat mild hypoglycemia
episodes.
5. Metformin increases hepatic glucose production to prevent hypoglycemia
associated with repaglinide.
, 6. Muscle pain is an expected side effect of metformin and may be treated with
acetaminophen (Tylenol).
1. Diarrhea can occur secondary to the metformin.
2. The repaglinide is not taken if a meal is skipped.
3. The repaglinide is taken 30 minutes before eating.
4. Candy or another simple sugar is carried and used to treat mild
hypoglycemia episodes.
Rationale:
Repaglinide is a rapid-acting oral hypoglycemic agent that stimulates
pancreatic insulin secretion that should be taken before meals, and that should
be withheld if the client does not eat. Hypoglycemia is a side effect of
repaglinide and the client should always be prepared by carrying a simple
sugar with her or him at all times. Metformin is an oral hypoglycemic given in
combination with repaglinide and works by decreasing hepatic glucose
production. A common side effect of metformin is diarrhea. Muscle pain may
occur as an adverse effect from metformin but it might signify a more serious
condition that warrants health care provider notification, not the use of
acetaminophen.
A client with Crohn's disease is scheduled to receive an infusion of infliximab
(Remicade). The nurse assisting in caring for the client should take which action to
monitor the effectiveness of treatment?
1. Monitoring the leukocyte count for 2 days after the infusion
2. Checking the frequency and consistency of bowel movements
3. Checking serum liver enzyme levels before and after the infusion