NCLEX Practice Exam for Pharmacological and Parenteral Therapies

EXPLANATION

✔Correct answer:

18 gauge. An 18 gauge catheter is the most appropriate choice for a 74-year-old patient undergoing a total hip replacement surgery. This gauge size is large enough to ensure adequate flow rates for intravenous fluids, blood products, and medications, which are often necessary during major surgical procedures. Although it might be slightly more uncomfortable to insert than smaller gauges, it is preferred for surgical patients because it can handle the rapid infusion of fluids and blood transfusions that may be required during and after the operation.

During surgery, patients often require large volumes of fluids and the ability to administer blood products quickly. The 18 gauge catheter's larger diameter allows for these needs to be met efficiently. Smaller gauge catheters may not provide sufficient flow rates, potentially compromising the patient's hemodynamic stability in critical situations.

Think of the IV catheter as a pipeline. An 18 gauge catheter is like a large pipe that can transport a substantial amount of water quickly, ensuring that the system (body) has an adequate and steady supply, especially in high-demand situations like surgery.

Nurse Ryan should ensure proper technique for inserting the 18 gauge catheter, considering the patient's age and vein condition. He should also monitor the site for complications and educate the patient on the importance of this larger gauge for surgical procedures.

• Prepare the IV site using aseptic techniques to minimize infection risk.
• Insert the 18 gauge catheter carefully to avoid damaging the vein.
• Secure the catheter and ensure proper labeling and documentation.
• Monitor the IV site regularly for signs of complications such as infiltration, phlebitis, or infection.
• Educate the patient about the purpose of the IV and the importance of monitoring for any complications.

✘Incorrect answer options:

20 gauge While a 20 gauge catheter is also suitable for many IV therapies, it might not provide the rapid infusion capability needed during major surgery, especially if blood products need to be administered quickly.

21 gauge butterfly A 21 gauge butterfly needle is typically used for short-term access, such as blood draws, and does not provide the necessary stability or flow rate for continuous infusions during surgery.

25 gauge A 25 gauge catheter is too small for the high flow rates required during major surgery. It is primarily used for very delicate veins or pediatric patients and would not be suitable for a surgical patient needing rapid fluid or blood administration.

EXPLANATION

✔Correct answer:

Avoid consuming chocolate and cheese. Patients taking monoamine oxidase inhibitors (MAOIs) need to avoid consuming foods high in tyramine, such as chocolate and cheese. MAOIs inhibit the enzyme monoamine oxidase, which breaks down tyramine in the body. Consuming high-tyramine foods while on MAOIs can lead to a hypertensive crisis, a dangerous and potentially life-threatening increase in blood pressure.

Tyramine is a naturally occurring amino acid that influences blood pressure. Normally, monoamine oxidase helps to metabolize and regulate tyramine levels in the body. When MAOIs block this enzyme, tyramine can accumulate to high levels if dietary intake is not controlled, leading to severe vasoconstriction and elevated blood pressure.

Think of the body as a dam that controls water flow (blood pressure). Normally, an enzyme (the dam gate) regulates the flow of water (tyramine). When the gate is blocked (by MAOIs), adding more water (tyramine-rich foods) can cause the dam to overflow (hypertensive crisis).

Nurse Maria should educate the patient about foods high in tyramine and the importance of avoiding them. She should also instruct the patient on recognizing the signs of hypertensive crisis, such as severe headache, chest pain, and palpitations, and to seek immediate medical attention if these occur.

• Provide a detailed list of high-tyramine foods to avoid, including aged cheeses, cured meats, fermented products, and certain alcoholic beverages.
• Explain the signs and symptoms of hypertensive crisis and the need for immediate medical intervention if these symptoms occur.
• Encourage the patient to read food labels and be cautious when dining out to avoid accidental consumption of high-tyramine foods.
• Advise the patient to consult their healthcare provider or pharmacist before taking any new medications, including over-the-counter drugs and supplements, as they may interact with MAOIs.

✘Incorrect answer options:

Take frequent naps throughout the day. While adequate rest is important for managing depression, there is no specific need to take frequent naps as a precaution related to MAOIs. This does not address the primary safety concern associated with these medications.

Take the medication along with milk. Taking MAOIs with milk does not have any significant impact on the safety or efficacy of the medication. This advice is irrelevant to the main dietary restriction needed for patients on MAOIs.

Refrain from walking without assistance. While some medications can cause dizziness or orthostatic hypotension requiring caution with ambulation, this is not a primary concern specific to MAOIs. The critical precaution for MAOIs is avoiding high-tyramine foods to prevent hypertensive crisis.

EXPLANATION

✔Correct answer:

Regularly monitor Tommy's serum glucose levels. Monitoring serum glucose levels is critical for patients receiving total parenteral nutrition (TPN) because TPN solutions contain high concentrations of glucose. Infusing these solutions can cause significant fluctuations in blood glucose levels, including hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose) if there is an interruption in the infusion. In pediatric patients, especially toddlers like Tommy, these fluctuations can be more pronounced and potentially dangerous. Therefore, frequent monitoring of serum glucose levels helps to ensure timely detection and correction of any abnormalities, which is crucial for maintaining metabolic stability and preventing serious complications.

TPN provides nutrition intravenously, bypassing the gastrointestinal tract, which can lead to rapid changes in blood glucose due to the high dextrose content. The body's normal regulatory mechanisms can be overwhelmed, leading to hyperglycemia. Additionally, if TPN is suddenly stopped, the patient may quickly develop hypoglycemia due to the abrupt cessation of the glucose supply.

Imagine TPN as a high-powered fuel being pumped directly into a car's engine. If the flow is too high, the engine (body) might overheat (hyperglycemia). If the fuel supply is suddenly cut off, the engine could sputter and stall (hypoglycemia). Monitoring the flow ensures the engine runs smoothly.

Nurses should regularly check blood glucose levels, particularly in the first 24-48 hours of TPN therapy, and be prepared to adjust the infusion rate or administer insulin if necessary.

• Use a glucometer to measure blood glucose levels as per the hospital protocol, typically every 4-6 hours initially.
• Observe for signs of hyperglycemia (e.g., increased thirst, frequent urination) and hypoglycemia (e.g., sweating, confusion, lethargy).
• Collaborate with the healthcare team to adjust TPN composition or rate based on glucose readings.
• Provide education to caregivers about the importance of glucose monitoring and potential signs of glucose imbalances.

✘Incorrect answer options:

Employ aseptic technique during dressing changes. While maintaining aseptic technique is essential to prevent infections, especially in central venous lines, it is a standard procedure that should always be followed. It does not specifically address the critical risk of metabolic complications associated with TTP.

Ensure the central line catheter remains intact. Ensuring the integrity of the central line is important to prevent complications such as infections or catheter-related issues, but it is part of routine central line care and not the most immediate critical concern when starting TPN.

Review the results of liver function tests. Liver function tests are important in the long-term monitoring of patients on TPN, as prolonged TPN use can lead to liver dysfunction. However, on the first day of therapy, immediate metabolic complications like blood glucose imbalances take precedence.

EXPLANATION

✔Correct answer:

Inform the physician that Mrs. Johanson is currently on oral contraceptives. The most appropriate initial nursing intervention is to inform the physician that Mrs. Johanson is currently on oral contraceptives. Tetracycline can potentially reduce the effectiveness of oral contraceptives, leading to an increased risk of unintended pregnancy. It is crucial to communicate this interaction to the physician so that they can provide appropriate guidance and consider alternative treatment options or additional contraceptive measures.

Tetracycline, an antibiotic, can interfere with the enterohepatic circulation of estrogens, thereby reducing the plasma concentrations of oral contraceptives. This interaction can compromise the effectiveness of the contraceptive, making it essential to address this issue before proceeding with the tetracycline treatment.

Think of oral contraceptives as a safety net and tetracycline as something that can create small holes in the net. Informing the physician allows them to ensure the net remains secure, preventing any accidents (unintended pregnancies).

Nurse Emily should promptly communicate with the physician about the potential interaction and collaborate to establish the best course of action for Mrs. Johanson. This may include recommending the use of additional contraceptive methods or selecting an alternative antibiotic that does not interact with oral contraceptives.

• Immediately inform the physician about Mrs. Johanson's use of oral contraceptives and the potential interaction with tetracycline.
• Discuss the need for additional contraceptive measures or consider alternative antibiotics.
• Educate Mrs. Johanson about the potential interaction and the importance of using additional contraception if advised by the physician.
• Document the communication with the physician and any changes to the treatment plan in the patient's medical record.

✘Incorrect answer options:

Proceed with administering the tetracycline dose. Administering tetracycline without addressing the potential interaction with oral contraceptives can lead to reduced contraceptive effectiveness and an increased risk of unintended pregnancy.

Advise Mrs. Johanson to discontinue her oral contraceptives as they are rendered ineffective by tetracycline. Discontinuing oral contraceptives without consulting the physician is inappropriate. The physician needs to be involved in deciding the best approach to managing the interaction.

Recommend Mrs. Johanson use an alternative form of contraception for the duration of the tetracycline treatment. While using an alternative form of contraception is a valid consideration, it is important first to inform the physician and follow their guidance regarding this recommendation.

EXPLANATION

✔Correct answer:

"It's used to prevent bacterial infections." Intravenous gamma globulin (IVIG) is used in patients with AIDS to boost the immune system and help prevent bacterial infections. IVIG contains pooled immunoglobulins (antibodies) from multiple donors, which can provide passive immunity and enhance the patient's ability to fight off infections. For immunocompromised individuals like Jordan, who have a weakened immune system due to AIDS, IVIG is crucial in reducing the risk of severe bacterial infections that their bodies might otherwise be unable to combat effectively.

Patients with AIDS have a compromised immune system due to the destruction of CD4+ T cells by the HIV virus. This makes them highly susceptible to opportunistic infections, including bacterial infections. IVIG provides exogenous antibodies that can help mitigate this risk by enhancing the immune response against bacterial pathogens.

Think of IVIG as reinforcements being sent to a weakened army. Jordan's immune system is like an army that has been severely weakened by AIDS. IVIG provides additional troops (antibodies) to help fight off bacterial invaders (infections).

Nurse Lucy should monitor Jordan for any adverse reactions to IVIG, such as allergic reactions, and educate the parents on the importance of infection prevention measures.

• Observe Jordan for signs of allergic reactions or side effects during and after IVIG administration.
• Educate Jordan's parents about common signs of infection and the importance of seeking prompt medical attention if symptoms occur.
• Encourage adherence to all prescribed medications and follow-up appointments to manage AIDS effectively.
• Provide support and resources to Jordan's parents to help them understand and cope with his condition.

✘Incorrect answer options:

"It helps to slow down the replication of the virus." IVIG does not have antiviral properties and does not affect the replication of HIV. Antiretroviral therapy (ART) is the standard treatment for slowing down HIV replication.

"This medication will enhance your child's overall health status." While IVIG can help reduce the risk of bacterial infections, it does not directly enhance overall health status or address the primary issue of HIV infection. This statement is too vague and does not accurately describe the specific role of IVIG.

"It boosts the effectiveness of the other medications your child is receiving." IVIG does not enhance the effectiveness of other medications. Its primary function is to provide passive immunity and help prevent bacterial infections, not to interact with or boost other treatments.

EXPLANATION

✔Correct answer:

In two to four hours. The patient can expect the first insulin peak in two to four hours after administration of regular insulin. Regular insulin, which is a short-acting insulin, typically begins to take effect within 30 minutes to 1 hour, peaks in two to four hours, and lasts for about six to eight hours.

Regular insulin mimics the body’s natural insulin response to meals, helping to lower blood glucose levels after eating. Its peak action occurs when it is most effective at lowering blood glucose levels, which is crucial information for patients to manage their meals and monitor for signs of hypoglycemia.

Think of regular insulin as a speedboat sent out to rescue people stranded on a lake (reduce high blood sugar). It starts moving quickly within the first half hour and does its most effective rescuing between two to four hours after launching, ensuring everyone is safe and the lake is clear.

Nurse Hannah should educate the patient on the timing of insulin action, especially the peak times, to help them plan their meals and activities appropriately and to be vigilant for signs of hypoglycemia during these periods.

• Explain the onset, peak, and duration of action of regular insulin and NPH insulin.
• Advise the patient to monitor their blood glucose levels more frequently around the peak times of their insulin doses.
• Discuss signs and symptoms of hypoglycemia (e.g., sweating, shaking, confusion) and how to treat it promptly.
• Recommend that the patient have a consistent meal and snack schedule to coincide with the peak times of insulin action.
• Provide guidance on carrying a quick source of glucose (e.g., glucose tablets, candy) to treat potential hypoglycemia.

✘Incorrect answer options:

As soon as food is ingested. This option is incorrect because regular insulin does not peak immediately. It starts working within 30 minutes to 1 hour after injection, but the peak effect occurs later.

In six hours. This is incorrect for regular insulin. While NPH insulin (intermediate-acting insulin) can peak around six to eight hours, regular insulin peaks much earlier, in two to four hours.

In ten to twelve hours. This is incorrect because it refers to the peak time of long-acting insulins or the duration of NPH insulin, not regular insulin. Regular insulin peaks much sooner, within two to four hours.

EXPLANATION

✔Correct answer:

Prednisone (Deltasone). Prednisone is a corticosteroid that provides both anti-inflammatory and immunosuppressive effects. It is commonly used in the treatment of rheumatoid arthritis to reduce inflammation and suppress the immune system's activity, which is responsible for the autoimmune response causing joint damage and pain in rheumatoid arthritis. Prednisone helps to quickly reduce symptoms and manage acute exacerbations of the disease.

In rheumatoid arthritis, the immune system mistakenly attacks the synovium, the lining of the membranes that surround the joints, causing inflammation, swelling, and pain. Corticosteroids like prednisone mimic the effects of cortisol, a hormone produced by the adrenal glands, to reduce inflammation and modulate the immune response.

Think of rheumatoid arthritis as a wildfire in the joints. Prednisone acts like a combination of water (anti-inflammatory) to douse the flames and fire retardant (immunosuppressive) to prevent the fire from spreading further.

Nurse Emma should monitor the patient for potential side effects of prednisone, such as increased blood glucose levels, weight gain, hypertension, and increased risk of infection due to its immunosuppressive effects. She should also educate the patient on the importance of adhering to the prescribed dosage and not discontinuing the medication abruptly.

• Monitor the patient's vital signs, blood glucose levels, and signs of infection.
• Educate the patient about potential side effects and the importance of reporting any unusual symptoms.
• Advise the patient to take prednisone with food to minimize gastrointestinal discomfort.
• Emphasize the need for regular follow-up appointments to adjust the dosage as needed.
• Discuss strategies for managing potential side effects, such as maintaining a healthy diet and exercising regularly to mitigate weight gain and hypertension.

✘Incorrect answer options:

Gold sodium thiomalate (Myochrysine) Gold compounds can reduce inflammation and modify the immune response, but their effects are primarily long-term and not as immediate as prednisone. They do not provide the same rapid anti-inflammatory effects needed for acute exacerbations.

Azathioprine (Imuran) Azathioprine is an immunosuppressive agent used in rheumatoid arthritis, but it does not have strong anti-inflammatory properties. It is more commonly used as a long-term therapy to suppress the immune system.

Naproxen (Naprosyn) Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that provides anti-inflammatory effects but does not have immunosuppressive properties. It is used to reduce pain and inflammation but does not modulate the immune response like prednisone.

EXPLANATION

✔Correct answer:

“I’ll probably need my daily insulin dose raised.” During pregnancy, especially in the second and third trimesters, insulin needs often increase due to the hormonal changes that cause insulin resistance. The placental hormones such as human placental lactogen, progesterone, and cortisol counteract insulin, making it necessary for many pregnant women with diabetes to increase their insulin dosage to maintain adequate blood glucose control.

As pregnancy progresses, the body's insulin resistance increases, requiring adjustments in insulin therapy to ensure that blood glucose levels remain within the target range. Failure to properly adjust insulin dosages can lead to poor glycemic control, increasing the risk of complications for both the mother and the baby, such as macrosomia, preeclampsia, and preterm birth.

Think of pregnancy as adding weight to a backpack you’re carrying. As the weight increases, you’ll need more strength (insulin) to keep carrying it effectively without stumbling (maintaining blood sugar control).

Nurse Lisa should continue to monitor the patient’s blood glucose levels closely and provide education on the importance of adjusting insulin dosages as needed. She should also discuss the potential signs of hypo- and hyperglycemia and the importance of maintaining regular blood glucose monitoring.

• Educate the patient about the typical increase in insulin requirements during pregnancy.
• Reinforce the importance of frequent blood glucose monitoring to track changes in insulin needs.
• Collaborate with the healthcare provider to adjust the insulin regimen as pregnancy progresses.
• Provide guidance on recognizing and managing symptoms of hypo- and hyperglycemia.
• Offer support and resources for managing diabetes during pregnancy, including dietary and lifestyle modifications.

✘Incorrect answer options:

“Are you sure all this insulin won’t hurt my baby?” This statement indicates a concern about the safety of insulin for the baby. Insulin does not cross the placenta and is safe for the fetus. However, it does not address the need for adjusting insulin dosages during pregnancy.

“I will continue to take my regular dose of insulin.” This statement indicates a misunderstanding of the need for potential adjustments in insulin dosages during pregnancy. Maintaining the same dose may not provide adequate glycemic control as insulin resistance increases.

“These finger sticks make my hand sore. Can I do them less frequently?” While frequent blood glucose monitoring can be uncomfortable, it is crucial for managing diabetes during pregnancy. Reducing the frequency of monitoring can lead to poor blood glucose control and increase the risk of complications.

EXPLANATION

✔Correct answer:

To identify any medications that could be contributing to his symptoms. The primary reason for Nurse Clara's request to list all prescription and nonprescription medications Mr. Thompson is taking is to identify any medications that could be contributing to his symptoms of sundown syndrome. Certain medications, particularly those that affect the central nervous system, can exacerbate confusion and disorientation in elderly patients, especially in the evening. By reviewing Mr. Thompson's medication list, Nurse Clara can determine if any of the drugs might be causing or worsening his symptoms and take appropriate action to adjust his medication regimen if necessary.

Sundown syndrome, also known as sundowning, is a condition where individuals with cognitive impairments, such as dementia, experience increased confusion and agitation during the late afternoon and evening. Medications such as benzodiazepines, anticholinergics, and certain pain medications can contribute to cognitive impairment and may exacerbate sundowning symptoms.

Imagine trying to figure out why a car is having trouble running smoothly. Checking the type and amount of fuel being used (medications) can reveal if there's something in the fuel that's causing the engine to malfunction, especially under specific conditions (like Mr. Thompson's symptoms worsening in the evening).

Nurse Clara should carefully review Mr. Thompson's medication list for any drugs that might cause or worsen confusion and agitation. She should also collaborate with the healthcare team to adjust the medication regimen as needed and monitor the patient's response.

• Review the list of all medications, including over-the-counter drugs, supplements, and herbal remedies.
• Identify any medications known to cause or exacerbate cognitive impairment, confusion, or agitation.
• Discuss potential medication adjustments with the healthcare provider to reduce or eliminate contributing drugs.
• Monitor Mr. Thompson's cognitive status and behavior throughout the day, particularly in the evening, to assess the effectiveness of any medication changes.
• Educate Mr. Thompson and his family about the potential effects of certain medications on cognitive function and the importance of medication management.

✘Incorrect answer options:

To ensure that Mr. Thompson is taking his medications as prescribed. While ensuring proper medication adherence is important, it is not the primary reason for reviewing the medication list in this context. The focus is on identifying medications that might be contributing to his symptoms.

To provide a complete medical history for future reference. Although having a complete medical history is beneficial, the immediate concern is identifying medications that could be causing or worsening Mr. Thompson's symptoms.

To verify that he is not taking any duplicate medications. While verifying that there are no duplicate medications is important to prevent overmedication and potential adverse effects, the primary goal in this scenario is to identify any medications contributing to his sundowning symptoms.

EXPLANATION

✔Correct answer:

Monitor the patient's glucose levels every 4-6 hours. Monitoring glucose levels every 4-6 hours is the most critical nursing action for a patient receiving total parenteral nutrition (TPN). TPN solutions are high in glucose, which can lead to significant fluctuations in blood glucose levels, including hyperglycemia. Hyperglycemia can cause severe complications such as dehydration, electrolyte imbalances, and increased risk of infection. Therefore, frequent monitoring of blood glucose allows for timely intervention to manage any abnormalities and maintain metabolic stability.

TPN delivers nutrients directly into the bloodstream, bypassing the gastrointestinal system, which can lead to rapid changes in blood glucose levels. This can overwhelm the body's natural insulin regulation mechanisms. Hyperglycemia, if not promptly addressed, can result in osmotic diuresis, leading to fluid and electrolyte imbalances, and can also impair immune function, increasing the risk of infections.

Think of TPN as a high-sugar energy drink being constantly infused. Just like someone drinking energy drinks regularly needs to monitor their blood sugar to avoid spikes, patients on TPN need regular glucose checks to maintain balanced blood sugar levels.

Nurse John should regularly check the patient's blood glucose levels using a glucometer, typically every 4-6 hours, especially during the initial phases of TPN therapy. Based on these readings, he should be ready to adjust the TPN rate or administer insulin as needed.

• Use a glucometer to measure blood glucose levels at scheduled intervals.
• Observe for signs of hyperglycemia (e.g., increased thirst, frequent urination) and hypoglycemia (e.g., sweating, confusion, lethargy).
• Collaborate with the healthcare team to adjust TPN composition or rate based on glucose readings.
• Provide education to the patient and family about the importance of glucose monitoring and the potential signs of glucose imbalances.

✘Incorrect answer options:

Administer the TPN at room temperature to avoid discomfort. While it is true that TPN should be administered at room temperature to prevent discomfort and vascular irritation, this is a standard practice and not the most critical action in terms of patient safety compared to monitoring glucose levels.

Ensure the TPN solution is infused over exactly 24 hours. While it is important to infuse TPN over the prescribed time to avoid complications such as hyperglycemia or fluid overload, the most immediate and critical action is to monitor glucose levels to detect and manage any immediate metabolic complications.

Change the TPN tubing every 72 hours. Changing TPN tubing every 72 hours is important to prevent infections, but it is a routine part of TPN management and does not require the same level of continuous and immediate monitoring as blood glucose levels.

EXPLANATION

✔Correct answer:

Monitor blood glucose levels every shift to detect development of hypo- or hyperglycemia. After an adrenalectomy, especially with an IV containing hydrocortisone running, it is essential to monitor blood glucose levels frequently. Hydrocortisone is a glucocorticoid, and it can significantly impact blood glucose levels, potentially causing hyperglycemia. Patients undergoing adrenalectomy are at risk of adrenal insufficiency and altered glucose metabolism, making blood glucose monitoring crucial for detecting hypo- or hyperglycemia.

The adrenal glands produce cortisol, a hormone involved in glucose metabolism. After adrenalectomy, the patient might experience fluctuations in cortisol levels, especially if exogenous hydrocortisone is administered. Hydrocortisone increases blood glucose levels by promoting gluconeogenesis and decreasing peripheral glucose uptake. Monitoring blood glucose ensures that any deviations from normal levels are detected and managed promptly.

Think of the body's glucose levels as a car's fuel gauge. Just as you need to monitor the fuel gauge regularly to ensure the car runs smoothly, you need to check blood glucose levels frequently to ensure the patient remains stable after surgery.

Nurse Alex should check the patient's blood glucose levels every shift and more frequently if necessary, to detect any signs of hypo- or hyperglycemia. He should also be prepared to administer insulin or glucose as needed based on the glucose readings.

• Check the patient’s blood glucose levels at least every shift or more frequently as needed.
• Observe for signs and symptoms of hypo- and hyperglycemia, such as confusion, sweating, tachycardia, or excessive thirst.
• Adjust the hydrocortisone dosage based on the patient’s response and blood glucose levels, as directed by the healthcare provider.
• Educate the patient about the importance of blood glucose monitoring and maintaining a balanced diet to manage blood sugar levels.
• Document all blood glucose readings and any interventions taken to maintain appropriate levels.

✘Incorrect answer options:

Keep the patient flat on their back with minimal movement to reduce the risk of hemorrhage following surgery. While minimizing movement post-surgery can help reduce the risk of hemorrhage, keeping the patient flat on their back is not necessary. It is more important to monitor for signs of bleeding and ensure appropriate positioning to prevent complications such as pneumonia or pressure ulcers.

Administer hydrocortisone until vital signs stabilize, then discontinue the IV. Hydrocortisone should not be discontinued abruptly after surgery. The patient may require ongoing steroid therapy to manage adrenal insufficiency, and the dosage should be tapered gradually under medical supervision.

Teach the patient how to care for the wound since he is at high risk for developing a postoperative infection. While wound care education is important, it is not the most immediate priority. Monitoring blood glucose levels is crucial in the immediate postoperative period, as it directly impacts the patient's stability and recovery.

EXPLANATION

✔Correct answer:

"I can continue using my regular salt substitute in my diet." This statement indicates a need for further teaching. Patients on lithium therapy need to maintain a consistent intake of sodium in their diet because lithium and sodium are processed similarly by the kidneys. Using salt substitutes, which often contain potassium instead of sodium, can lead to an imbalance that affects lithium levels in the body, potentially causing toxicity or decreased efficacy.

Lithium is a mood stabilizer used in the treatment of bipolar disorder. It is excreted by the kidneys, and its excretion is influenced by sodium levels. A decrease in sodium intake or an increase in sodium loss (e.g., through dehydration or excessive sweating) can lead to higher lithium levels in the blood, increasing the risk of toxicity. Conversely, a high sodium intake can result in lower lithium levels, reducing its effectiveness.

Think of lithium and sodium as two friends who compete for a ride on the same bus (kidneys). If one friend (sodium) doesn't show up, the other friend (lithium) will take all the seats, leading to an overload (toxicity). If too many friends (sodium) show up, the original friend (lithium) might not get a seat, reducing its presence in the body.

Nurse Alex should educate the patient on the importance of maintaining a consistent sodium intake and avoiding salt substitutes. He should also discuss the need for adequate hydration and regular blood monitoring to ensure safe and effective lithium therapy.

• Explain the relationship between sodium intake and lithium levels, emphasizing the importance of a consistent sodium intake.
• Advise against the use of salt substitutes that contain potassium.
• Encourage the patient to stay well-hydrated, especially during activities that increase sweating.
• Reiterate the importance of taking lithium with food to minimize gastrointestinal upset.
• Remind the patient about the necessity of regular blood level checks to monitor lithium levels and adjust dosages as needed.

✘Incorrect answer options:

"I need to drink plenty of water and avoid becoming dehydrated." This is correct and important advice for patients on lithium therapy, as dehydration can increase lithium levels and the risk of toxicity.

"I should take my lithium with food to avoid stomach upset." This statement is also correct. Taking lithium with food can help prevent gastrointestinal irritation, which is a common side effect.

"I need to have my blood levels checked regularly while on lithium." Regular monitoring of blood lithium levels is crucial to ensure that the medication remains within the therapeutic range and to adjust the dosage as necessary to avoid toxicity.

EXPLANATION

✔Correct answer:

Intense burning pain lasting a few minutes after application. Mafenide acetate (Sulfamylon) is a topical antimicrobial agent used to treat burn wound infections, particularly those caused by Gram-negative organisms. A well-known side effect of this medication is intense burning pain at the site of application, which typically lasts for a few minutes. It is important for Nurse Megan to prepare the patient for this expected response to ensure they are not alarmed and understand that the discomfort is temporary.

Mafenide acetate penetrates eschar and provides broad-spectrum antimicrobial activity. The burning sensation is due to the drug's ability to penetrate deep into tissues, which is essential for treating infected burn wounds but also causes temporary pain.

Imagine applying a strong antiseptic to a deep cut. The antiseptic cleans and disinfects the wound effectively but causes a brief, intense stinging sensation. Similarly, Sulfamylon works deeply to treat infections but causes short-term pain.

Nurse Megan should educate the patient about the temporary burning sensation they will feel upon application of the medication. She should also provide reassurance and support to help the patient manage the discomfort. Additionally, monitoring for other side effects and ensuring proper application techniques are essential.

• Inform the patient that a brief, intense burning sensation is expected and typically subsides within a few minutes.
• Reassure the patient that the burning is a normal response and indicates the medication is penetrating the tissue effectively.
• Monitor the wound and surrounding skin for signs of adverse reactions or infection.
• Ensure that the medication is applied correctly and consistently as prescribed.
• Provide emotional support and comfort measures, such as distraction techniques or mild analgesics, if needed.

✘Incorrect answer options:

Risk of severe metabolic alkalosis with prolonged use. Mafenide acetate can cause metabolic acidosis, not alkalosis, as a potential side effect due to its carbonic anhydrase inhibiting properties. This requires monitoring but is not the immediate sensation the patient will experience upon application.

Dark staining of all materials that contact the drug. Sulfamylon does not cause dark staining of materials. This is more commonly associated with other topical agents like silver sulfadiazine.

Feeling cold due to evaporation from the moist dressings. While patients might feel cold from evaporation with other types of dressings, this is not a typical response specifically related to the application of Sulfamylon. The primary concern immediately after application is the burning sensation.

EXPLANATION

✔Correct answer:

Vomiting. Vomiting is an early sign of digitalis (digoxin) toxicity, especially in young children. Digoxin is used to improve cardiac function in patients with congestive heart failure, but it has a narrow therapeutic index, meaning the difference between a therapeutic dose and a toxic dose is small. Early detection of toxicity is crucial to prevent serious complications.

Digoxin toxicity can occur due to the accumulation of the drug in the body, leading to an overdose. It affects the gastrointestinal system, causing symptoms such as nausea, vomiting, and abdominal pain. These symptoms often appear before more severe signs of toxicity, such as cardiac arrhythmias or CNS disturbances.

Think of digoxin as a medicine with a very fine line between enough and too much. If too much is taken, the stomach starts to react first, similar to how you might feel nauseated if you eat too much rich food.

Nurse Emily should closely monitor the child for signs of digoxin toxicity, including vomiting, nausea, poor feeding, and lethargy. If any of these symptoms occur, she should withhold the medication and notify the healthcare provider immediately for further assessment and potential adjustment of the digoxin dosage.

• Monitor the child’s heart rate and rhythm regularly, as bradycardia can also indicate toxicity.
• Check serum digoxin levels if toxicity is suspected to confirm the diagnosis.
• Educate the parents about the signs of digoxin toxicity and the importance of adhering to the prescribed dosage.
• Ensure accurate dosing by using an appropriate measuring device.
• Keep the healthcare provider informed of any symptoms or concerns related to digoxin therapy.

✘Incorrect answer options:

Bradypnea. Bradypnea, or slow breathing, is not a typical early sign of digoxin toxicity. Respiratory symptoms are not usually the first indicators of toxicity in children on digoxin.

Failure to thrive. Failure to thrive is a chronic condition indicating poor growth and development over time, not an acute symptom of digoxin toxicity. While it may be a concern in children with chronic heart conditions, it is not specific to digoxin toxicity.

Tachycardia. Tachycardia, or rapid heart rate, is not an early sign of digoxin toxicity. In fact, digoxin is typically used to help control heart rate in conditions like heart failure and atrial fibrillation, and toxicity usually presents with bradycardia (slow heart rate) rather than tachycardia.

EXPLANATION

✔Correct answer:

The opinions of the patient’s friends about taking medication. While social support and the opinions of friends can influence a patient's attitude towards medication, it is the least likely factor to directly impact the patient's compliance with lithium therapy compared to the other factors listed. Compliance with lithium therapy is more critically influenced by the direct effects and management of the medication, such as its impact on the patient's energy level and lifestyle, the need for regular blood monitoring, and the potential side effects, which can significantly affect the patient's willingness and ability to adhere to the prescribed regimen.

Lithium is a mood stabilizer commonly used in the treatment of bipolar disorder. It has a narrow therapeutic range, requiring regular blood level monitoring to avoid toxicity and ensure efficacy. The medication can cause side effects such as tremors, weight gain, and thyroid dysfunction, which can impact the patient's daily life and overall adherence to the therapy.

Imagine adhering to a diet plan. Factors like how the diet makes you feel (energy levels), the need for regular check-ins (monitoring), and the taste or side effects of the diet (potential side effects) are primary influencers. The opinions of friends are less likely to affect whether you stick to the diet if it significantly impacts your daily routine and health directly.

Nurse Alex should focus on educating the patient about the importance of regular monitoring, managing potential side effects, and how lithium might affect their lifestyle. She should also provide strategies for overcoming these challenges to support adherence to the therapy.

• Educate the patient about the importance of regular blood level monitoring to prevent toxicity.
• Discuss potential side effects and how to manage them effectively.
• Explain how lithium therapy might impact daily energy levels and lifestyle, and provide coping strategies.
• Encourage the patient to communicate with their healthcare provider about any concerns or side effects experienced.
• Provide resources for support groups or counseling to help the patient manage their condition and treatment adherence.

✘Incorrect answer options:

The impact of lithium on the patient’s energy level and lifestyle. Lithium can affect the patient's energy levels and lifestyle significantly, making this a critical factor in determining adherence.

The need for regular monitoring of blood levels. Regular blood monitoring is essential to ensure safe and effective lithium therapy, and it can be a significant burden, influencing compliance.

The potential side effects of lithium. Side effects of lithium, such as tremors, weight gain, and thyroid dysfunction, can greatly affect the patient's quality of life and willingness to continue the medication.

EXPLANATION

✔Correct answer:

Symptoms of polyarthritis. Polyarthritis, or inflammation in multiple joints, is a common manifestation of rheumatic fever and is one of the major criteria for its diagnosis. Salicylates, such as aspirin, are commonly prescribed to reduce inflammation, pain, and fever associated with polyarthritis in rheumatic fever. The continuation of salicylates is important to manage these symptoms effectively and prevent further complications.

Rheumatic fever is an inflammatory disease that can develop after a group A Streptococcus infection, such as strep throat. It can cause widespread inflammation, particularly affecting the heart, joints, skin, and brain. Polyarthritis occurs due to the inflammatory response triggered by the infection, leading to painful and swollen joints. Salicylates help reduce this inflammation and alleviate pain.

Imagine your body's joints as door hinges. In rheumatic fever, the hinges become rusty and hard to move (inflamed and painful). Salicylates act like oil for the hinges, making them easier to move and reducing the rust (inflammation).

Nurse Karen should educate the patient and the parents on the importance of continuing the salicylate therapy as prescribed to manage polyarthritis symptoms and to monitor for any adverse effects of the medication. She should also reinforce the importance of regular follow-up visits to adjust the treatment plan as needed.

• Educate the patient and parents on the correct dosage and timing of salicylates.
• Advise on monitoring for side effects such as gastrointestinal upset or signs of bleeding.
• Emphasize the importance of adherence to the medication regimen to prevent symptom recurrence.
• Encourage regular follow-up appointments for ongoing assessment and management.

✘Incorrect answer options:

Presence of chorea. Chorea (involuntary, rapid movements) is a neurological manifestation of rheumatic fever, but it is not typically treated with salicylates. Chorea may require other specific treatments, such as anticonvulsants or corticosteroids.

Subcutaneous nodules. Subcutaneous nodules are another manifestation of rheumatic fever but are not directly treated with salicylates. They generally resolve on their own without specific treatment.

Erythema marginatum rash. This distinctive rash is associated with rheumatic fever but does not require treatment with salicylates. The primary focus of salicylate use is to manage the inflammatory symptoms such as polyarthritis.

EXPLANATION

✔Correct answer:

A blood glucose level of 350 mg/dl. A blood glucose level of 350 mg/dl is significantly elevated and requires immediate attention when administering total parenteral nutrition (TPN). Hyperglycemia is a common complication associated with TPN because the solution contains high concentrations of glucose. Such elevated glucose levels can lead to serious complications, including hyperglycemic hyperosmolar syndrome (HHS), dehydration, electrolyte imbalances, and increased risk of infection. Immediate intervention is necessary to prevent these complications and stabilize the patient's metabolic status.

TPN bypasses the gastrointestinal tract, directly infusing glucose into the bloodstream. This can overwhelm the body's insulin response, leading to elevated blood glucose levels. If not addressed, hyperglycemia can cause osmotic diuresis, leading to dehydration and electrolyte imbalances, and can further impair immune function.

Think of the bloodstream as a highway and glucose as cars. TPN can flood the highway with too many cars (glucose), causing a traffic jam (hyperglycemia). Immediate measures are needed to clear the congestion (normalize blood glucose levels).

Immediate actions should include notifying the healthcare provider, checking for additional signs of hyperglycemia, and possibly adjusting the TPN infusion rate or initiating insulin therapy.

• Recheck the blood glucose level to confirm the reading.
• Notify the healthcare provider of the elevated blood glucose level.
• Prepare to administer insulin as prescribed to lower the blood glucose level.
• Monitor for signs of hyperglycemia, such as increased thirst, frequent urination, and fatigue.
• Educate the patient and family about the signs and symptoms of hyperglycemia and the importance of glucose monitoring.

✘Incorrect answer options:

A temperature of 37.5 degrees Celsius. While a slight increase in temperature can be concerning, especially for potential infection in a patient with a central line, 37.5 degrees Celsius is within the normal range for many individuals and does not require immediate intervention.

Urine output of 300 cc in 4 hours. This urine output is within normal limits for an adult, indicating adequate kidney function and hydration status. It does not necessitate immediate intervention.

Poor skin turgor. Poor skin turgor indicates dehydration, which is a concern but not as immediately critical as a dangerously high blood glucose level. Dehydration can be addressed with fluid management, but it does not require the same urgent intervention as hyperglycemia.

EXPLANATION

✔Correct answer:

Reduce the size and vascularity of the thyroid and prevent hemorrhage. Lugol’s solution, an iodine and potassium iodide solution, is administered preoperatively to patients with hyperthyroidism undergoing thyroidectomy primarily to reduce the size and vascularity of the thyroid gland. This reduction in vascularity helps to minimize intraoperative bleeding and makes the thyroid gland easier to remove.

Hyperthyroid patients typically have an enlarged and highly vascular thyroid gland due to increased blood flow and cellular activity. Iodine in Lugol’s solution temporarily inhibits the release of thyroid hormones and decreases the gland's blood supply. This effect reduces the risk of excessive bleeding during surgery and helps to stabilize the patient’s thyroid function before the operation.

Think of the thyroid gland as a water balloon filled with lots of tiny blood vessels. Lugol’s solution acts like a temporary sealant that reduces the balloon's size and the number of blood vessels, making it easier to handle without bursting during surgery.

Nurse Sarah should ensure the patient understands the purpose of Lugol’s solution and monitor for any adverse reactions. She should also provide education on how to take the medication correctly and assess the patient’s thyroid function and overall health status preoperatively.

• Explain the purpose of Lugol’s solution in reducing thyroid size and vascularity to the patient.
• Monitor the patient for any side effects or allergic reactions to iodine.
• Ensure the patient takes the medication as prescribed, typically a few days to a week before surgery.
• Assess the patient’s thyroid function tests and overall health status before the surgery.
• Provide emotional support and address any concerns the patient may have about the surgery and medication.

✘Incorrect answer options:

Decrease the risk of agranulocytosis postoperatively. Agranulocytosis, a severe decrease in white blood cells, is a potential side effect of antithyroid drugs like methimazole or propylthiouracil, not of Lugol’s solution. Lugol’s solution is not used for this purpose.

Prevent tetany while the patient is under general anesthesia. Tetany is related to low calcium levels and is a risk if the parathyroid glands are inadvertently damaged during thyroid surgery. Calcium supplements or other measures are used to prevent tetany, not Lugol’s solution.

Enhance the effect of other preoperative medications, allowing for lower doses during anesthesia. While Lugol’s solution stabilizes thyroid function, its primary role is not to enhance other medications or reduce anesthesia doses. Its main function is to reduce thyroid gland size and vascularity to prevent hemorrhage.

EXPLANATION

✔Correct answer:

"The medication must be continued to manage the fluid buildup." In patients with congestive heart failure (CHF), diuretics are a cornerstone of therapy to manage fluid overload and prevent exacerbations of heart failure symptoms. Congestive heart failure is a chronic condition, and diuretics help to remove excess fluid from the body, thereby reducing the workload on the heart and preventing symptoms such as edema and shortness of breath. The need for diuretics is typically ongoing to maintain fluid balance and prevent hospitalizations due to heart failure exacerbations.

In CHF, the heart's ability to pump blood is compromised, leading to fluid retention in tissues and the lungs. Diuretics help the kidneys remove excess fluid and sodium from the body, reducing the volume of blood the heart must pump and decreasing pressure on the cardiovascular system.

Think of your heart as a sink that drains slowly due to a partial clog. If you keep adding water (fluid) without addressing the slow drainage, the sink will overflow. Diuretics act like a plunger, helping to clear out excess water and prevent the overflow, but they need to be used regularly to keep the drain functioning properly.

Nurse Samantha should educate Mr. Thompson on the importance of adhering to his prescribed diuretic therapy and monitoring for signs of fluid retention or electrolyte imbalances. She should also emphasize the need for regular follow-up with his healthcare provider to adjust the medication as needed.

• Explain the role of diuretics in managing CHF and preventing fluid buildup.
• Instruct Mr. Thompson to take his diuretics as prescribed and not to skip doses.
• Advise him to monitor his weight daily and report significant weight gain to his healthcare provider, as it may indicate fluid retention.
• Educate him on recognizing signs of fluid overload, such as swelling, shortness of breath, and fatigue, and to seek medical attention if these symptoms occur.
• Discuss the importance of regular follow-up appointments to adjust medications and monitor kidney function and electrolytes.

✘Incorrect answer options:

"As you urinate more, you will need less medication to control fluid." This statement is misleading as the need for diuretics in CHF is ongoing and based on the patient's condition, not just the immediate effect of increased urination.

"You will have to take this medication for about a year." CHF is a chronic condition, and diuretic therapy is usually required long-term, not just for a finite period like one year.

"Please discuss medications and treatments with your physician." While it is always important to involve the physician in discussions about medication management, this response does not provide the patient with the necessary information about the chronic nature of CHF and the need for ongoing diuretic therapy.

EXPLANATION

✔Correct answer:

Complaints of pain at the infusion site. Complaints of pain at the infusion site require immediate action when administering an intravenous vesicant chemotherapeutic agent. Vesicant agents can cause severe tissue damage and necrosis if they extravasate (leak) into surrounding tissues. Pain at the infusion site can be an early sign of extravasation, which needs to be addressed promptly to prevent significant complications.

Vesicants are chemotherapeutic agents that can cause blistering and severe tissue injury if they escape from the vein into the surrounding tissue. Extravasation can lead to tissue necrosis, infection, and loss of function in the affected area. Early detection and intervention are crucial to minimize tissue damage and preserve function.

Imagine a highly corrosive substance being accidentally spilled on the skin. Immediate action is needed to wash it off and prevent burns. Similarly, if a vesicant leaks into tissues, quick action is necessary to prevent severe injury.

Nurse Alex should immediately stop the infusion if the patient complains of pain at the infusion site, assess the site for signs of extravasation, and follow the institution's protocol for managing extravasation. This may include notifying the healthcare provider, administering antidotes, and applying cold or warm compresses as appropriate.

• Stop the infusion immediately upon complaints of pain at the site.
• Assess the infusion site for signs of redness, swelling, or blistering.
• Follow extravasation management protocols, which may include aspirating any residual vesicant from the IV line, administering specific antidotes, and applying appropriate compresses.
• Notify the healthcare provider promptly for further instructions.
• Document the incident thoroughly, including the patient's symptoms, the steps taken, and the outcome.

✘Incorrect answer options:

Presence of a stomatitis lesion in the mouth. Stomatitis (inflammation and sores in the mouth) is a common side effect of chemotherapeutic agents but does not require immediate intervention during an infusion. It should be addressed with appropriate oral care and symptom management.

Severe episodes of nausea and vomiting. While severe nausea and vomiting are distressing and need to be managed, they do not require the same immediate action as extravasation. Antiemetic medications can be administered to help control these symptoms.

Development of a rash on the extremities. A rash could indicate an allergic reaction or side effect of the chemotherapeutic agent, but it does not require the same urgent intervention as the potential tissue damage from extravasation. Allergic reactions should be monitored and managed according to protocol, but pain at the infusion site takes precedence during the infusion of a vesicant.