A client is receiving diazepam IV, a benzodiazepine anticonvulsant, for status epilepticus. Which intervention is most important for the practical nurse (PN) to implement?

Record hourly blood pressures for the next 4 hours

Measure hourly urinary output for the next 8 hours

Monitor the client’s respiratory rate and effort

Observe the client’s eyes for deviation to the side

Answer and Explanation

The Correct Answer is C

Choice A reason: Recording blood pressures is relevant, as diazepam may cause hypotension, but it is less critical than respiratory monitoring. Status epilepticus requires rapid seizure control, and diazepam’s respiratory depression risk is more immediate, as it can lead to life-threatening hypoxia if not addressed promptly.

Choice B reason: Measuring urinary output monitors renal function but is not urgent in status epilepticus. Diazepam’s primary risk is respiratory depression, not renal effects. Ensuring airway and breathing stability is more critical, as seizures and the drug both threaten respiratory function, making this choice secondary.

Choice C reason: Monitoring respiratory rate and effort is critical, as diazepam, a CNS depressant, can cause respiratory depression, especially in status epilepticus, where seizures already compromise breathing. Hypoventilation risks hypoxia, potentially leading to brain damage or death, making this the most urgent intervention to ensure airway safety.

Choice D reason: Observing eye deviation may indicate ongoing seizures but is less urgent than respiratory monitoring. Diazepam controls seizures, but its side effect of respiratory depression poses an immediate threat. Ensuring adequate ventilation is the priority to prevent hypoxia during acute seizure management.

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Correct Answer is A

Explanation

Choice A reason: Increasing pain before the next opioid dose suggests inadequate analgesia, possibly due to tolerance or disease progression. Consulting the charge nurse facilitates dosage adjustment or schedule changes, ensuring effective pain control in terminal cancer, where maintaining comfort is critical for quality of life.

Choice B reason: Notifying the provider that the dosage has been increased is incorrect, as the PN cannot unilaterally adjust controlled substances. Pain management requires collaboration, and premature notification without consultation risks legal and clinical errors, making this choice inappropriate.

Choice C reason: Withholding opioid doses risks uncontrolled pain, which is unethical in terminal cancer care. The client’s increasing pain indicates a need for dosage review, not cessation, as opioids are essential for palliation, making this choice harmful and contrary to care goals.

Choice D reason: Administering opioids only when pain exceeds 5 is arbitrary and delays relief. Breakthrough pain before scheduled doses requires proactive dosage or interval adjustments, not reactive thresholds, to maintain consistent analgesia, making this choice inadequate for managing terminal cancer pain.

A. Stop the drug if nausea, vomiting, and/or prostration occur B. Avoid all sources of alcohol while taking this drug, including cough syrups C. The medication should be taken at the same time each day D. Have weekly blood tests to determine therapeutic drug levels and serum sodium

Correct Answer is B

Explanation

Choice A reason: Stopping disulfiram for nausea or vomiting is incorrect, as these are expected in alcohol reactions, not side effects warranting discontinuation. Disulfiram inhibits aldehyde dehydrogenase, causing acetaldehyde buildup if alcohol is consumed, leading to these symptoms, which reinforce alcohol avoidance.

Choice B reason: Avoiding all alcohol, including in cough syrups, is critical, as disulfiram causes severe reactions (flushing, nausea) by blocking acetaldehyde metabolism. Even small amounts trigger symptoms, reinforcing abstinence in alcohol dependence treatment, making this the most important instruction for safety and efficacy.

Choice C reason: Taking disulfiram at the same time daily promotes adherence but is less critical than avoiding alcohol, which directly prevents severe reactions. Consistency aids therapeutic levels, but alcohol exposure poses immediate health risks, making this instruction secondary.

Choice D reason: Weekly blood tests are not standard for disulfiram, as therapeutic levels are not routinely monitored, and sodium is unaffected. Liver function may be checked periodically, but alcohol avoidance is the priority to prevent acute reactions, making this choice incorrect.

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A client is receiving diazepam IV, a benzodiazepine anticonvulsant, for status epilepticus. Which intervention is most important for the practical nurse (PN) to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with terminal cancer reports increasing pain that occurs 1 to 2 hours before the next scheduled dose of a prescribed opioid analgesic. Which action should the practical nurse (PN) implement?

Correct Answer is A

Explanation

The practical nurse (PN) is reviewing the discharge medication instructions with a client for disulfiram. Which instruction should the PN reinforce with the client?

Correct Answer is B

Explanation

The practical nurse (PN) is preparing to administer a maintenance dose of an antihypertensive medication to an adult client and notes that the client’s blood pressure is 120/72 mm Hg. Which action should the PN take?

The practical nurse (PN) is reinforcing information with a client who has been diagnosed with human immunodeficiency virus (HIV) about the antiretroviral medication regimen. Which client statement should the PN recognize as requiring an additional review of the information?

The practical nurse (PN) notes that a home health client who is taking a fluoroquinolone to treat a respiratory infection is sitting on an uncovered, outdoor porch. Which action should the PN take?

A client with depression who is taking a tricyclic antidepressant (TCA) reports frequent early morning awakening and difficulty going back to sleep. Which information from the client is important for the practical nurse (PN) to obtain to improve the client’s sleep pattern?

A client is receiving tetracycline for chlamydia urethritis. The practical nurse (PN) should reinforce which instruction?

A client who is taking sildenafil 50 mg PO PRN reports experiencing visual changes to the practical nurse (PN). Which instruction should the PN give to the client?

The practical nurse (PN) is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the PN should further assess the prescription?

Which client information should the practical nurse (PN) obtain prior to preparing a dose of the influenza vaccine?