A nurse is reviewing the medication administration record of a client who has hypocalcemia and a new prescription for IV calcium gluconate. The nurse should identify that which of the following medications can interact with calcium gluconate?
A. Felodipine
B. Guaifenesin
C. Digoxin
D. Regular insulin | C. Digoxin
Rationale:
The nurse should identify that calcium gluconate can cause hypercalcemia, which increases the risk of digoxin toxicity.
Calcium gluconate does not interact with felodipine.
Calcium gluconate does not interact with guaifenesin.
Calcium gluconate does not interact with insulin. |
A nurse is teaching a client who is taking allopurinol for the treatment of gout. Which of the following information should the nurse include in the teaching?
A. Plan to increase the dosage each week by 200 mg increments.
B. Prolonged use of the medication can cause glaucoma.
C. Drink 2 L of water daily.
D. A fine red rash is transient and can be treated with antihistamines. | C. Drink 2 L of water daily.
Rationale:
The nurse should instruct the client to drink at least 2 L of water each day to prevent renal stone formation and kidney injury, because allopurinol is eliminated through the kidneys.
The nurse should instruct the client to report a rash to the provider immediately as this can be an indication of hypersensitivity syndrome, a life-threatening toxicity. Treatment for allopurinol toxicity can require hemodialysis or the administration of glucocorticoid medications.
The nurse should instruct the client to increase the dosage each week by 50 to 100 mg until they experience relief or reach a maximum of 800 mg daily.
The nurse should instruct the client that the prolonged use of allopurinol can cause cataracts. Therefore, the client should have periodic ophthalmic checkups. |
A nurse is caring for a client who has heart failure and is receiving an IV infusion of dopamine. Which of the following findings indicates that the medication is effective?
A. Decreased blood pressure
B. Increased heart rate
C. Increased cardiac output
D. Decreased serum potassium | C. Increased cardiac output
Rationale:
Dopamine is an adrenergic that causes a receptor specificity effect, which increases cardiac output and improves perfusion.
Dopamine is an adrenergic that causes a receptor specificity effect, which increases blood pressure.
Tachycardia is an adverse effect of dopamine and does not indicate the medication's effectiveness.
Dopamine does not affect serum potassium levels. |
A nurse is preparing to administer medications to a client who tells the nurse, "I don't want to take my fluid pill until I get home today." Which of the following actions should the nurse take?
A. File an incident report with the risk manager.
B. Document the refusal and inform the client's provider.
C. Contact the pharmacist to pick up the medication.
D. Give the client the medication to take at home and document that it was administered. | B. Document the refusal and inform the client's provider.
Rationale:
The nurse has the responsibility to verify that the client understands the risks of refusing the medication so that an informed decision can be made. The nurse should then document the refusal in the client's medical record and notify the health care provider.
The nurse does not need to complete an incident report if a client refuses to take a medication. An incident report is necessary for a medication error.
The nurse should follow facility protocols for discarding the medication. It is not the role of the pharmacist to retrieve medications that a client refuses to take.
The nurse should not give the client a scheduled medication to take at home and then document that it was administered, because this violates the ethical principle of accountability. |
A nurse is caring for a client who is experiencing acute alcohol withdrawal. For which of the following client outcomes should the nurse administer chlordiazepoxide?
A. Minimize diaphoresis
B. Maintain abstinence
C. Lessen craving
D. Prevent delirium tremens | D. Prevent delirium tremens
Rationale:
The client should take chlordiazepoxide to prevent delirium tremens during acute alcohol withdrawal.
The client should take clonidine or a beta-adrenergic blocker, such as atenolol, to minimize autonomic components, such as diaphoresis, during alcohol withdrawal.
The client should take acamprosate to help maintain abstinence from alcohol by decreasing anxiety and other uncomfortable manifestations.
The client should take propranolol to decrease cravings during alcohol withdrawal. |
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. Fill out an incident report.
D. Check the client's blood glucose. | D. Check the client's blood glucose.
Rationale:
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.
The nurse should fill out an incident report to document the incident. However, there is another action the nurse should take first. The incident report alerts the risk manager to the incident, who then determines the cause and a plan of action to reduce the risk of reoccurrence.
The nurse should notify the provider to protect the client from injury. However, there is another action the nurse should take first.
The nurse should report the incident to the charge nurse to protect the client from injury. However, there is another action the nurse should take first. |
A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take?
A. Administer the medication outside the 5-cm (2-in) radius of the umbilicus.
B. Aspirate for blood return before injecting.
C. Rub vigorously after the injection to promote absorption.
D. Place a pressure dressing on the injection site to prevent bleeding. | A. Administer the medication outside the 5-cm (2-in) radius of the umbilicus.
Rationale:
The nurse should administer the heparin by subcutaneous injection to the abdomen in an area that is above the iliac crest and at least 5 cm (2 in) away from the umbilicus.
The nurse should not aspirate by pulling back on the plunger of the heparin syringe to check for a blood return, because this will cause the injection site to bruise.
The nurse should apply firm pressure to the injection site for 1 to 2 min after the administration of the heparin to prevent bruising.
The nurse does not need to apply a dressing over the injection site if pressure is held for at least 1 min to prevent bleeding. |
A client is prescribed a second dose of IV ceftriaxone postoperatively. The nurse notes urticaria and dyspnea. Which of the following actions should the nurse prioritize?
A. Administer oxygen.
B. Administer diphenhydramine.
C. Notify the charge nurse.
D. Discontinue the infusion. | D. Discontinue the infusion.
Rationale:
The greatest risk to the client is anaphylaxis. Therefore, the priority intervention is to stop the medication.
Administering oxygen is an appropriate intervention for dyspnea. However, this is not the priority action currently relative to the client's situation.
Administering diphenhydramine is an appropriate intervention for urticaria. However, this is not the priority action currently relative to the client's situation.
Notifying the charge nurse is an appropriate intervention. However, this is not the priority action currently relative to the client's situation. |
A nurse is monitoring an older adult client who has heart failure for adverse effects of hydrochlorothiazide after administering the medication. Which of the following findings should the nurse identify as an adverse effect of the medication?
A. Hypoglycemia
B. Orthostatic hypotension
C. Bradycardia
D. Conjunctivitis | B. Orthostatic hypotension
Rationale:
The nurse should identify that hydrochlorothiazide is an antihypertensive thiazide diuretic medication, which can cause orthostatic hypotension and light headedness. Therefore, the nurse should instruct the client to rise slowly when moving from a recumbent to a standing position.
Hydrochlorothiazide is an antihypertensive thiazide diuretic medication, which can cause hyperglycemia.
The nurse should identify palpitations as an adverse effect of hydrochlorothiazide, which is an antihypertensive thiazide diuretic medication.
The nurse should identify that hydrochlorothiazide is an antihypertensive thiazide diuretic medication and may have the adverse effects of blurred vision and xanthopsia, which causes objects to appear yellow. Conjunctivitis is not an adverse effect of this medication. |
A nurse is reviewing the medical record of a client who has schizophrenia and a prescription for clozapine. Which of the following laboratory tests should the nurse review before administering the medication?
A. Troponin
B. Total cholesterol
C. Creatinine
D. Thyroid stimulating hormone | B. Total cholesterol
Rationale:
The nurse should review the client's total cholesterol before administering clozapine, because this medication can cause hyperlipidemia.
The nurse should review the troponin level of a client who has chest pain and possible myocardial infarction.
Clozapine is not metabolized by the kidneys. Therefore, the nurse does not need to review the creatinine level before administering the medication.
The nurse should review the thyroid stimulating hormone level of a client who has hypothyroidism or hyperthyroidism. |
A nurse is providing teaching to a client who is to start treatment for asthma with beclomethasone and albuterol inhalers. Which of the following instructions should the nurse include in the teaching?
A. "Take beclomethasone to avoid an acute attack."
B. "Use beclomethasone 5 minutes before using albuterol."
C. "Limit your calcium and vitamin D intake when taking beclomethasone."
D. "Rinse your mouth after inhaling the beclomethasone." | D. "Rinse your mouth after inhaling the beclomethasone."
Rationale:
The client should rinse their mouth after using beclomethasone, a glucocorticoid inhaler, to prevent oropharyngeal candidiasis and hoarseness.
The client should take albuterol, a short-acting beta2-adrenergic agonist, to avoid an acute asthma attack.
The client should use the bronchodilator, albuterol, prior to taking beclomethasone, a glucocorticoid inhaler, to enhance its absorption.
The client should increase the intake of calcium and vitamin D to minimize bone loss while taking beclomethasone, a glucocorticoid inhaler. |
A nurse is assessing a client who has received atropine eye drops during an eye examination. Which of the following findings should the nurse expect as an effect of the medication?
A. Difficulty seeing in the dark
B. Pinpoint pupils
C. Blurred vision
D. Excessive tearing | C. Blurred vision
Rationale:
Blurred vision is an expected finding following the administration of atropine eye drops. This is due to the cycloplegic effects of the medication, which cause near objects to appear blurry to the client.
Blurred vision is an expected finding following the administration of atropine eye drops. This is due to the cycloplegic effects of the medication, which cause near objects to appear blurry to the client.
Dilation of pupils, or mydriasis, is an expected finding following the administration of atropine eye drops.
Excessive tearing is not an expected finding following the administration of atropine eye drops. |
A nurse is teaching a client about the use of risedronate for the treatment of osteoporosis. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?
A. "I will drink a glass of milk when I take the risedronate."
B. "I will take the risedronate 15 minutes after my evening meal."
C. "I should take an antacid with the risedronate to avoid nausea."
D. "I should sit up for 30 minutes after taking the risedronate." | D. "I should sit up for 30 minutes after taking the risedronate."
Rationale:
Sitting upright for at least 30 min after taking risedronate will reduce the adverse gastrointestinal effects of esophagitis and dyspepsia. Risedronate is contraindicated for a client who cannot sit or stand upright for this length of time.
The nurse should reinforce that risedronate should be taken with a full glass of water, rather than any other liquid.
Although the delayed release form of the medication can be taken after eating, the immediate release form of the medication should be taken at least 30 min prior to consuming food or other liquids. Both forms of medication should be taken in the morning.
The absorption of risedronate, a bisphosphonate, will be reduced if it is taken with antacids containing calcium, aluminum, or magnesium. The nurse should instruct the client to take the antacid 2 hr after taking risedronate. |
A nurse is reviewing the laboratory results of a client who is taking digoxin for heart failure. Which of the following results should the nurse report to the provider due to it increasing the risk for digoxin toxicity?
A. Decreased platelet count
B. Decreased albumin level
C. Decreased hematocrit
D. Decreased potassium level | D. Decreased potassium level
Rationale:
The nurse should notify the provider if a client has hypokalemia prior to administration of digoxin due to the increased risk of developing digoxin toxicity and cardiac dysrhythmias.
A decreased platelet count can increase the client's risk for bleeding. However, it does not increase the risk for digoxin toxicity.
A decreased albumin level can indicate malnutrition, liver disorders, or severe inflammation, such as with burns. However, it does not increase the risk for digoxin toxicity.
A decreased hematocrit can indicate anemia, hemorrhage, or certain types of cancers. However, it does not increase the risk for digoxin toxicity. |
A nurse is administering diazepam to a client who is having a colonoscopy. Which of the following actions should the nurse take?
A. Ensure flumazenil is available to administer for toxicity management.
B. Monitor the client for an increase in blood pressure.
C. Expect the client to become unconscious within 30 seconds.
D. Measure the capnography level every hour until the client is awake and oriented. | A. Ensure flumazenil is available to administer for toxicity management.
Rationale:
The nurse should monitor the client for manifestations of diazepam toxicity, such as respiratory depression and hypotension. The nurse should be prepared to administer flumazenil to reverse the effects of diazepam.
The nurse should monitor the client for the adverse effect of hypotension.
When diazepam is administered IV for induction of anesthesia, the nurse should expect the client to develop the full effect of the medication in 2 min.
The nurse should measure the capnography level every 15 to 30 min until the client is awake and oriented and vital signs have returned to baseline. |
A nurse is providing teaching to a client who is to start therapy with digoxin. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?
A. Dry cough
B. Pedal edema
C. Bruising
D. Yellow-tinged vision | D. Yellow-tinged vision
Rationale:
The nurse should instruct the client to monitor for and report yellow-tinged vision, which is a sign of digoxin toxicity. Other manifestations of digoxin toxicity include nausea, vomiting, loss of appetite, and fatigue. As the digoxin levels increase, the client can experience cardiac dysrhythmias.
Clients taking an anticoagulant, such as enoxaparin, might develop bruising and should report this adverse effect to the provider. However, hematologic adverse effects are not associated with digoxin.
Clients taking a calcium channel blocker, such as verapamil, might develop pedal edema and should report this adverse effect to the provider. However, peripheral edema is not associated with digoxin.
Clients taking an ACE inhibitor, such as captopril, might develop a dry cough due to a buildup of bradykinin and should report this adverse effect to the provider. However, respiratory adverse effects are not associated with digoxin. |
A nurse is reviewing the ECG of a client who is receiving IV furosemide for heart failure. The nurse should identify which of the following findings as an indication of hypokalemia?
A. Tall, tented T-waves
B. Presence of U-waves
C. Widened QRS complex
D. ST elevation | B. Presence of U-waves
Rationale:
The nurse should identify the presence of U-waves as a manifestation of hypokalemia, an adverse effect of furosemide.
The nurse should identify tall, tented T-waves as a manifestation of hyperkalemia. Flattened or inverted T-waves are a manifestation of hypokalemia.
The nurse should identify a widened QRS complex as a manifestation of hyperkalemia.
The nurse should identify ST elevation is an indication of ischemia. ST depression is a manifestation of hypokalemia. |
A nurse is teaching a client about cyclobenzaprine. Which of the following client statements should the indicate to the nurse that the teaching if effective?
A. "I will have increased saliva production."
B. "I will continue taking the medication until the rash disappears."
C. "I will taper off the medication before discontinuing it."
D. "I will report any urinary incontinence." | C. "I will taper off the medication before discontinuing it."
Rationale:
The client should taper off cyclobenzaprine before discontinuing it to prevent abstinence syndrome or rebound insomnia.
The client should use gum or sip on water to prevent dry mouth, which is an adverse effect of cyclobenzaprine.
The client should take cyclobenzaprine for treatment of muscle spasms. This medication does not affect skin rashes.
The client should report any urinary retention because of the anticholinergic effects caused when taking cyclobenzaprine. |
A nurse is teaching a client who has been prescribed tamoxifen for breast cancer treatment. Which of the following adverse effects of this medication should the nurse include in the teaching?
A. Hot flashes
B. Urinary retention
C. Constipation
D. Bradycardia | A. Hot flashes
Rationale:
The estrogen receptor blocking action of tamoxifen commonly results in the adverse effect of hot flashes.
Tamoxifen can cause genitourinary adverse effects such as vaginal discharge and uterine cancer. However, urinary retention is not an expected adverse effect of tamoxifen.
Gastrointestinal adverse effects of tamoxifen include nausea and vomiting. However, constipation is not an expected adverse effect of tamoxifen.
Tamoxifen is an antiestrogen medication that works by blocking estrogen receptors. Cardiovascular adverse effects of the medication include chest pain, flushing, and the development of thrombus. However, bradycardia is not an expected adverse effect of tamoxifen. |
A nurse is teaching about self-administration of transdermal medication with a client who has a new prescription for nitroglycerin. Which of the following client statements indicates an understanding of the teaching?
A. "I can apply the patch to a chest area that has hair."
B. "I can take this medication while using an erectile dysfunction product."
C. "I will remove the patch after 14 hours."
D. "I need to apply a new patch to the same area every day." | C. "I will remove the patch after 14 hours."
Rationale:
The client should remove the patch after 12 to 14 hr to prevent tolerance of the medication.
The client should apply the patch to an area of the skin that is hairless to enhance absorption of the medication.
The client should not use erectile dysfunction products while taking nitroglycerin because this combination can cause severe hypotension and death.
The client should rotate the location of the patch daily to avoid irritation of the skin. |
A nurse is completing an incident report for a medication error. Which of the following information should the nurse include in the report?
A. This could have been avoided if I had double checked the medication administration record with the client's identification band.
B. It was easy to get confused because another client is receiving a similar sounding medication.
C. While I rarely make medication errors, the client was given 80 mg of propranolol by mistake at 1800.
D. Administered propranolol 80 mg PO at 1800 to the client who did not have a prescription for the medication. | D. Administered propranolol 80 mg PO at 1800 to the client who did not have a prescription for the medication.
Rationale:
The incident report should clearly and thoroughly report the facts of the error.
The incident report should clearly and thoroughly report the facts of the error. It should not include the nurse's opinion as to how the error might have been prevented.
The incident report should clearly and thoroughly report the facts of the error. It should not include the nurse's opinion as to why the error might have occurred.
The incident report should clearly and thoroughly report the facts of the error. It should not include statements by the nurse regarding personal characteristics. |
A nurse is caring for a 20-year-old client who has a prescription for isotretinoin for severe nodulocystic
acne vulgaris. Before the client can obtain a refill, the nurse should advise the client that which of the following tests is required?
A. Serum calcium
B. Pregnancy test
C. 24-hr urine collection for protein
D. Aspartate aminotransferase level | B. Pregnancy test
Rationale:
The nurse should instruct the client that isotretinoin has teratogenic effects. Therefore, pregnancy must be ruled out before the client can obtain a refill. The client must provide two negative pregnancy tests for the initial prescription and one negative test before monthly refills.
The client does not need to have a laboratory test for serum calcium levels while taking isotretinoin.
The client does not need to have a 24-hr urine test for protein levels when taking isotretinoin.
The client should have a laboratory test for aspartate aminotransferase levels prior to starting isotretinoin, 1 month after starting the medication, and periodically thereafter. However, a laboratory test for aspartate aminotransferase is not required to renew a prescription for isotretinoin. |
A nurse is caring for a client who is receiving haloperidol. Which of the following findings should the nurse identify as an adverse effect of the medication?
A. Paresthesia
B. Akathisia
C. Excess tear production
D. Anxiety | B. Akathisia
Rationale:
An adverse effect associated with haloperidol is the development of extrapyramidal manifestations such as dystonia, pseudoparkinsonism, and akathisia.
Haloperidol, an antipsychotic neuroleptic medication, can cause CNS adverse effects, such as seizures, confusion, and neuroleptic syndrome. However, paresthesia is not an adverse effect of haloperidol.
Haloperidol has anticholinergic properties that can cause sensory adverse effects, such as increased intraocular pressure, blurred vision, and dry eyes.
Haloperidol can be prescribed to treat severe agitation as well as psychotic manifestations. |
A nurse is providing discharge instructions to a client who is to self-administer insulin at home. Which of the following client statements should indicate to the nurse that the teaching is effective?
A. "I should avoid getting rid of the air bubble in the syringe."
B. "I should inject the insulin into my thigh for the fastest absorption."
C. "I will store my unopened bottles of insulin in the refrigerator."
D. "I need to shake the insulin before using it to make sure it is well mixed." | C. "I will store my unopened bottles of insulin in the refrigerator."
Rationale:
The client should store unopened vials of insulin in the refrigerator to maintain medication viability. Once opened, the insulin can remain at room temperature for up to 1 month.
The nurse should instruct the client to expel all air bubbles in the syringe to ensure an accurate dosage is delivered.
The nurse should instruct the client that the fastest absorption of insulin occurs with abdominal injections. Absorption is slowest when the injection is into the thigh.
The nurse should instruct the client to mix insulin by rolling the insulin in the palm of their hand to prevent frothing, which can cause the drawing up of an inaccurate dose of insulin. |
A nurse is teaching a group of unit nurse about medication reconciliation. Which of the following information should the nurse include in the teaching?
A. The client's provider is required to complete medication reconciliation.
B. Medication reconciliation at discharge is limited to the medication ordered at the time of discharge.
C. A transition in care requires the nurse to conduct medication reconciliation.
D. Medical reconciliation is limited to the name of the medications that the client is currently taking. | C. A transition in care requires the nurse to conduct medication reconciliation.
Rationale: The nurse should conduct medication reconciliation anytime the client is undergoing a change in care, such as admission, transfer from one unit to another, or discharge. A complete listing of all prescribed and over-the-counter medications should be reviewed. The nurse or a member of the health care team, such as the pharmacist, is required to complete medication reconciliation. Medication reconciliation at discharge includes medications ordered at the time of discharge, over-the-counter medications, vitamins, herbal supplements, nutritional supplements, and other medications the client is taking. The name of the current medication and new medication, over-the-counter medications, vitamins, herbal supplements, and nutritional supplements are included at the medication reconciliation. The indication, route, dosage size, and dosing interval are also required. |
A nurse on a mental health unit is caring for a client.
Provider Prescriptions
Day 1, 0900: Fluphenazine 2.5 mg PO four times dailyRegular diet
Nurses' Notes: Day 1, 0900: Client admitted from emergency department for psychosis. Client diagnosed with schizophrenia approximately 5 years ago, has had one prior hospitalization for psychosis. Client exhibiting disorganized, pressured speech and agitation. Also reports hearing voices and appears fearful.
Day 3, 0800: LPN entered client's room to administer medication and noted that client did not respond to verbal or tactile stimulation, was diaphoretic, and hot to palpation. Notified RN. Vital signs obtained. Client noted to be incontinent of urine. Client mumbles in response to painful stimuli, muscle rigidity noted. Provider notified. Vital Signs: Day 1, 0900: Temperature 36.9° C (98.4° F), Heart rate 88/min, Blood pressure 124/82 mm Hg, Respiratory rate 18/min, SpO2 9 | A. Apply a cooling blanket
B. Administer bromocriptine
C. Administer dantrolene
F. Discontinue fluphenazine
Rationale: When taking actions, the nurse should administer dantrolene and bromocriptine, apply a cooling blanket, and discontinue the fluphenazine. The client is exhibiting manifestations of neuroleptic malignant syndrome (NMS), a potentially fatal adverse effect of antipsychotic medications, such as fluphenazine. Other manifestations can include electrolyte imbalance, delirium, and dysrhythmias. Dantrolene and bromocriptine can relieve muscle rigidity and decrease body temperature. Cooling blankets can also assist in decreasing body temperature. The fluphenazine should be discontinued and the client should be transferred to a critical care unit for ongoing treatment. |
A nurse at a clinic is evaluating a client.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence. Vital Signs: Temperature 37.7°C (99.9°F),
Heart rate 110/min, Respiratory rate 20/min, Blood pressure 126/74 mmHg, SaO2 95% on room air. Notes: Today: Adult female client is here for 3 month follow up visit after receiving a new prescription 3 months ago. Client reports feeling nervous and being irritable. Client is alert and oriented to person place and time. Skin moist and intact some sweating noted on forehead. Heart rate regular and fast. Respirations even and non-labored. Bowel sounds hyperactive in all 4 quadrants. Reports occasional loose stools that have increased lately. Lab Results: TSH 0.1 mU/L (0.3 to 5 mU/L);
Triiodothyronine 220 ng/dL (70 to 205 ng/dL); Thyroxine 4 ng/dL (0.8 to 2.8 ng/dL); Provider Prescriptions: 3 months ago: Levothyroxine 50 mcg PO daily | The client is likely experiencing hyperthyroidism as evidenced by the client's blood thyroxine level.
Rationale: When evaluating outcomes for a client who has taken levothyroxine for 3 months, the nurse should determine that the client is likely experiencing hyperthyroidism as evidenced by the client's blood thyroxine level. Levothyroxine is thyroid hormone that is used to treat clients who have hyperthyroidism. An adverse effect of levothyroxine is hyperthyroidism which is manifested by findings of increased metabolism such a nervousness, irritability, diaphoresis, tachycardia, and laboratory findings of decreased thyroid stimulating hormone (TSH) and elevated thyroid hormone levels (triiodothyronine and thyroxine). |
A nurse is caring for a female older adult on a medical-surgical unit.
History and Physical5 Days Ago: Past Medical HistoryHypertension
Congestive heart failure, Physical:Client alert and oriented x3. Lung sounds clear to auscultation. S1, S2 present, no extra heart sounds. Peripheral pulses 2+ in all extremities. Client reported flank pain and dysuria. Client had an outpatient urine culture done which was positive for Escherichia coli. Client was admitted for intravenous antibiotic therapy. Height 160 cm (63 in), weight 65 kg (144 lb).
Medication Administration Record. Gentamicin 5mg/kg once daily IVCefazolin 1 g every 8 hr IVFurosemide 20 mg once daily by mouth
Laboratory Results. 2 Days Ago: Gentamicin trough 2.5 mcg/mL (less than 2 mcg/mL). 1 Day Ago: Gentamicin trough 3 mcg/mL (less than 2 mcg/mL), Today: Blood urea nitrogen (BUN) 22 mg/dL (10 to 20 mg/dL). Creatinine 1.3 mg/dL (0.5 to 1.2 mg/dL). Gentamicin peak | The client is at greatest risk for nephrotoxicity due to kidney function.
Rationale: When prioritizing hypothesis, the nurse should recognize that the client is most at risk for developing nephrotoxicity. The client has elevated BUN and creatinine levels indicating altered kidney function. The risk of nephrotoxicity is increased when concurrent use of other ototoxic drugs like furosemide are used. When trough levels are consistently elevated, ototoxicity can occur, but this is not the immediate concern. |
Nurses' Notes: 3 days ago, 1200: Client is admitted due to postoperative infection. The proximal end of the abdominal incision is open and draining a large amount of thick yellow drainage. Peripheral IV initiated in the right antecubital space. Cultures obtained. Height 175 cm (69 inches), weight 89 kg (197 lb).
Provider Prescriptions: 3 days ago, 1100: Initiate IV for antibiotic therapy. Obtain and send to laboratory, blood cultures, abdominal incision drainage cultures, electrolytes, BUN, creatinine, CBC
Administer gentamicin IV 5 mg/kg once dailyAdminister acetaminophen PO 650 mg every 6 hr for temperature above 38.5° C (101.3° F). Yesterday, 1100: Obtain blood specimen and send for gentamycin trough level once daily prior to gentamycin dose.
Medication Administration RecordToday, 1300: Gentamycin 445 mg IV Acetaminophen 650 mg PO
Laboratory Results
Yesterday:
Abdominal incision drainage culture: Po | -BUN 48 mg/dL (10 to 20 mg/dL)
-Creatinine 2.7 mg/dL (0.5 to 1.1 mg/dL)
-Output 60mL
-Urine is dark amber.
Rationale:
When recognizing cues, the nurse should review the client's EMR, the nurse should recognize the client's elevated BUN, elevated creatinine level, urine output of less than 30mL/hr, and dark amber colored urine are manifestations of nephrotoxicity which is an adverse effect gentamycin and other aminoglycosides. Therefore, the nurse should hold the dose until further directions from the provider. |
A nurse is preparing to administer a client's prescribed medications.
Vital Signs: 0815: Temperature 37.7° C (97.8° F), Heart rate 90/min
Respiratory rate 16/min, Blood pressure 126/74 mmHg, SaO2 97% on room air. Nurses' Notes: 0815: Client has history of fibromyalgia and is being admitted for pain management. Client rates pain as 7 on a scale of 0 to 10. Client is alert and oriented to person place and time. Skin dry and intact. Heart rate regular with S1 and S2 present. Respirations even and non-labored. Bowel sounds hyperactive in all 4 quadrants. 20 G IV saline lock present in the right basilic. Provider Prescriptions: 0900: Fentanyl 25 mcg/hr apply transdermal every 72 hr. Morphine sulfate 4 mg IV bolus every 2 hr as needed for pain | -clean the iv injection port with an antiseptic swab -flush the IV,
-check for blood return -clean area on skin with soap and water
-Sterile gloves?
Rationale: When generating solutions, the nurse should prepare to administer morphine sulfate via IV bolus route. Therefore, prior to administering the medication, the nurse should clean the injection port with an antiseptic swab to prevent infection, flush the IV catheter with 0.9% sodium chloride before and after to ensure and maintain patency of the IV, and check for blood return to ensure the IV is in the vein. When administering a fentanyl transdermal patch, the nurse should apply clean gloves and cleanse the skin area with soap and water. |