Which action is a priority for the nurse when finding medications at a clients bedside quizlet?

The correct answer is 2, 3, 4, 5 .

The nurse should encourage the client to drink a commercial product, such as Lactaid, in which the lactose has been preconverted into other absorbable sugars.Lactase enzyme preparations are available, without prescription, to improve milk tolerance. Yogurt containing bacterial lactase is another option that may be tolerated.The nurse should explain that lactose is a digestive enzyme that converts lactose, the sugar in milk, into simpler sugars.The nurse should advise the client to obtain calcium through other sources, such as green leafy vegetables, dates, prunes, canned sardines and salmon with bones, egg yolks, whole grains, dried peas, beans, and calcium supplements.

The correct answer is 1, 2, 3, 4, 5

When caring for a client diagnosed with bulimia nervosa, it is essential for the nurse to monitor the client for at least an hour after meals to prevent the client from purging.When caring for this client, the goal is to identify situations that produce anxiety that may cause the client to binge eat.The goal here is to decrease situations that produce anxiety. Providing a quiet, non-stimulating environment will assist in decreasing the client's anxiety. The nurse should obtain the client's weight every day at the same time using the same scale. Establishing a client contract is important. The contract, which encourages the client to assume responsibility for actions, should include an agreement about binge eating, purging or vomiting, and hoarding of food.

The correct answer is 1, 2, 5

Citrus fruits are high in potassium and should be avoided, as kidneys cannot excrete excess potassium. Other foods that are high in potassium include dried fruits, avocado, tomato, potatoes, and bananas. This statement indicates that additional teaching is needed.Kidney failure can lead to hypocalcemia, and regular intake of calcium is needed. However, dairy products are high in phosphorus, which binds to calcium and should be avoided. This statement indicates that additional teaching is needed.Excess dietary protein increases uric acid, a byproduct of protein metabolism, which is cleared by the kidneys. In kidney failure, kidneys will be unable to excrete urea, and low to normal amounts of dietary protein are prescribed. This statement indicates that additional teaching is needed.

Neck stiffness or soreness

Rationale: Phenelzine sulfate, a monoamine oxidase inhibitor (MAOI), is an antidepressant and is used to treat depression. Hypertensive crisis, an adverse effect of this medication, is characterized by hypertension, frontally radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The client is taught to be alert to any occipital headache radiating frontally and neck stiffness or soreness, which could be the first signs of a hypertensive crisis. Dry mouth and restlessness are common side effects of the medication.

(Anatomy with the appearance and dimpled texture of an orange peel.)

Rationale: Peau d'orange (French for "orange peel") is the term used to describe skin dimpling, resembling the skin of an orange, at the location of a breast mass. This change, along with increased vascularity, nipple retraction, or ulceration, may indicate advanced disease. Erythema, or reddening, of the breast indicates inflammation such as that resulting from cellulitis or a breast abscess. Paget's disease is a rare type of breast cancer that is manifested as a red, scaly nipple; discharge; crusting lasting more than a few weeks. In nipple retraction, the nipple is pointed or pulled in an abnormal direction. It is suggestive of malignancy.

Document the findings

Rationale: Lithium carbonate is a mood stabilizer that is used to treat manic-depressive illness. Side effects include polyuria, mild thirst, and mild nausea, and therefore the nurse would simply document the findings. Because the client's complaints are side effects, not toxic effects, contacting the health care provider, instituting seizure precautions, and having a specimen drawn immediately for a serum lithium determination are all unnecessary. Vomiting, diarrhea, muscle weakness, tremors, drowsiness, and ataxia are signs of toxicity and if these occur the health care provider needs to be notified.

Decreased fluid volume

Rationale: Sickle cell disease is a genetic disorder that is manifested as chronic anemia, pain, disability, organ damage, increased risk for infection, and early death. In this disorder the red blood cells assume a sickle shape, become rigid, and clump together. Dehydration can precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and the fetus, including interruption of blood flow to the respiratory system and placenta. Decreased fluid volume is the priority concern in this situation, followed by decreased nutrition. Inability to tolerate activity and inability to cope compete for third priority, depending on the client's specific symptoms at the time.

Drowsiness

Rationale: Chlorpromazine is an antipsychotic, antiemetic, antianxiety, and antineuralgia adjunct. Common side effects of chlorpromazine include drowsiness, blurred vision, hypotension, defective color vision, impaired night vision, dizziness, decreased sweating, constipation, dry mouth, and nasal congestion. Headache, photophobia, and urinary frequency are not specific side effects of this medication.

July 2, 2018

Rationale: Accurate use of Nagele's rule requires that the woman have a regular 28-day menstrual cycle. To calculate the EDD with the use of this rule, the nurse would subtract 3 months from the date of the first day of her LMP, add 7 days, and then adjust the year. First day of the LMP, September 25, 2017; subtract 3 months, June 25, 2017; add 7 days, July 2, 2017; add 1 year, July 2, 2018.

Encouraging the client to deep-breathe, cough, and use an incentive spirometer

Rationale: Care after abdominal hysterectomy includes maintenance of a patent airway, promotion of circulation and oxygenation, promotion of comfort, monitoring of output and drainage, promotion of elimination, and discharge teaching with regard to medications and therapeutic regimens. The priority is the maintenance of a patent airway and promotion of oxygenation and circulation. Monitoring the client for signs of returning peristalis, instructing her in dietary habits to prevent constipation, and encouraging her to talk about the effects of her surgery are also components of care after this surgery but are of lower priority than encouraging the client to deep-breathe, cough, and use an incentive spirometer.

That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol

Rationale: Disulfiram is an alcohol abuse deterrent prescribed to motivated clients who have shown the ability to stay sober. Driving is not prohibited; however, the client is instructed to use caution when driving and performing other tasks that require alertness. The medication is taken daily (not just when the client has a desire to drink alcohol), and the effects of the medication last 5 days to 2 weeks after the last dose is taken. The medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol. Otherwise, an alcohol-disulfiram reaction will occur, with effects consisting of facial flushing, sweating, a throbbing headache, neck pain, tachycardia, respiratory distress, a potentially serious decrease in blood pressure, and nausea and vomiting. This reaction may last 30 to 120 minutes.

*Fever
*Vasculitis
*Abdominal pain

Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory disorder of the connective tissue that can cause the failure of major organs and body systems. Manifestations include fever, fatigue, anorexia, weight loss, vasculitis, discoid lesions, and abdominal pain. Erythema, usually in a butterfly pattern (hence the nickname "butterfly rash"), appears over the cheeks and bridge of the nose. Other manifestations include nephritis, pericarditis, the Raynaud phenomenon, pleural effusions, joint inflammation, and myositis.

Which of the following actions is one of the 10 rights of medication administration?

Which of the following actions demonstrates correct use of one of the ten rights of medication?

What action should the charge nurse take?

Which of the following clients should the nurse see first?