A nurse is preparing to administer a hazardous IV medication to a client. Which of the following actions should the nurse take?

Wear gloves when handling the medication.

Administer the medication in a negative pressure room.

Administer the medication while wearing protective footwear.

Wear an N95 respiratory mask when administering the medication.

Answer and Explanation

The Correct Answer is A

A) Wear gloves when handling the medication: This is the correct action to take when preparing to administer a hazardous IV medication. Wearing gloves helps protect the nurse from direct contact with the medication, reducing the risk of exposure to potentially harmful substances.

B) Administer the medication in a negative pressure room: While some hazardous medications may require administration in a negative pressure room to prevent the spread of airborne contaminants, this is not a standard precaution for administering IV medications. Negative pressure rooms are typically used for airborne infection isolation rather than for medication administration.

C) Administer the medication while wearing protective footwear: While wearing appropriate footwear is important for general safety in healthcare settings, it is not specifically required for administering hazardous IV medications. Protective footwear may be necessary in certain situations, such as when handling biohazardous materials or when there is a risk of spills, but it is not directly related to IV medication administration.

D) Wear an N95 respiratory mask when administering the medication: While respiratory protection may be necessary when handling certain hazardous substances, such as those that produce airborne particles or aerosols, it is not typically required for administering IV medications. N95 masks are primarily used for respiratory protection in situations where there is a risk of inhaling airborne contaminants, such as infectious agents or hazardous chemicals.

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Correct Answer is B

Explanation

Distended neck veins: Distended neck veins are typically associated with fluid volume excess rather than deficit. In heart failure, venous congestion can cause jugular venous distention, indicating fluid volume overload rather than deficit. Therefore, this finding would not suggest fluid volume deficit in a client with heart failure receiving furosemide.
B) Elevated hematocrit level: Fluid volume deficit, also known as dehydration or hypovolemia, is characterized by a loss of both water and electrolytes from the body, leading to a relative increase in the concentration of red blood cells and other blood components. This increase in concentration results in an elevated hematocrit level, which is a common laboratory finding in clients with fluid volume deficit. Furosemide, a loop diuretic, is commonly used to manage fluid overload in clients with heart failure by promoting diuresis and reducing excess fluid retention. However, excessive diuresis with furosemide can lead to fluid volume deficit if not adequately monitored and managed.

C) Shortness of breath: Shortness of breath is a common symptom of heart failure, particularly when fluid accumulates in the lungs (pulmonary edema) due to fluid volume overload. While shortness of breath may be present in both fluid volume deficit and excess, it is more commonly associated with fluid volume overload in clients with heart failure.

D) Weight gain: Weight gain is indicative of fluid volume excess rather than deficit. In heart failure, weight gain often occurs due to fluid retention, reflecting an increase in total body water and extracellular fluid volume. Monitoring weight is essential in managing heart failure and assessing fluid status, but weight gain would not suggest fluid volume deficit in a client receiving furosemide for heart failure management.

A. Morphine 2 mg IV B. Amitriptyline 25 mg PO C. Ketorolac 15 mg IV D. Acetaminophen 650 mg PO

Correct Answer is C

Explanation

A) Morphine 2 mg IV: Morphine is a potent opioid analgesic commonly used to manage moderate to severe pain. However, in this scenario, the client reports pain as 5 on a scale of 0 to 10, which indicates moderate pain. Morphine 2 mg IV may be excessive for this level of pain and could result in unnecessary sedation, respiratory depression, or other opioid-related adverse effects. Therefore, it is not the most appropriate choice for managing the client's pain.

B) Amitriptyline 25 mg PO: Amitriptyline is a tricyclic antidepressant with analgesic properties, but it is not typically used as a first-line treatment for acute postoperative pain. Additionally, it is administered orally and may not provide rapid pain relief in the immediate postoperative period. Therefore, it is not the most suitable option for managing the client's pain after a total knee replacement surgery.

C) Ketorolac 15 mg IV: Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that provides potent analgesic and anti-inflammatory effects. It is commonly used for the management of moderate to severe pain, including postoperative pain. In this scenario, the client reports moderate pain after total knee replacement surgery, making ketorolac an appropriate choice for pain management. Administering ketorolac 15 mg IV can provide effective pain relief without the sedative effects of opioids, making it the most suitable PRN medication for the client's pain level.

D) Acetaminophen 650 mg PO: Acetaminophen is a non-opioid analgesic commonly used for mild to moderate pain relief. While acetaminophen is generally safe and effective, it may not provide sufficient pain relief for a client who reports pain as 5 on a scale of 0 to 10 after total knee replacement surgery. Additionally, oral administration may result in delayed onset of action compared to IV medications. Therefore, acetaminophen 650 mg PO may not be the most optimal choice for managing the client's pain in this situation.

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A nurse is preparing to administer a hazardous IV medication to a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

Correct Answer is B

Explanation

A nurse is preparing to administer pain medication to a postoperative client who had a total knee replacement and reports pain as 5 on a scale of 0 to 10. Which of the following PRN medications should the nurse plan to administer?

Correct Answer is C

Explanation

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