A nurse is preparing to administer lansoprazole 30 mg PO daily to a client. The amount available is lansoprazole 10 mg per tablet. How many tablets should the nurse administer per dose?

(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Choice A: Pain Level
The client reports a pain level of 7 on a scale of 0 to 10. Postoperative pain is expected, but a pain level of 7 indicates severe pain that requires immediate attention. Effective pain management is crucial for postoperative recovery as unmanaged pain can lead to complications such as increased heart rate, elevated blood pressure, and delayed
healing. The nurse should assess the effectiveness of the current pain management plan and consider administering additional analgesics or adjusting the pain management strategy. Pain should be reassessed frequently to ensure the client is comfortable and to prevent complications associated with severe pain.

Choice B: Blood Pressure
The client’s blood pressure is 138/72 mmHg, which is within the normal range for adults (systolic 90-120 mmHg and diastolic 60-80 mmHg). While slightly elevated, this blood pressure reading does not require immediate follow-up in the context of postoperative care unless there are other symptoms indicating a hypertensive crisis or other cardiovascular issues. It is important to monitor blood pressure regularly, but in this scenario, it is not one of the critical findings that require immediate intervention.

Choice C: Lung Sounds
Crackles heard upon auscultation in the posterior lungs and the client being dyspneic are significant findings that require immediate follow-up. Crackles can indicate fluid accumulation in the lungs, which may be a sign of pulmonary edema or pneumonia. Dyspnea, or difficulty breathing, further supports the need for urgent assessment and intervention. The nurse should perform a thorough respiratory assessment, monitor oxygen saturation levels, and notify the healthcare provider. Interventions may include administering supplemental oxygen, positioning the client to improve ventilation, and possibly initiating diuretic therapy if fluid overload is suspected.

Choice D: Incision Site
The incision site has purulent drainage, redness, and warmth, which are classic signs of infection. Postoperative infections can lead to serious complications, including sepsis if not promptly addressed. The nurse should assess the incision site for additional signs of infection, such as increased swelling, foul odor, or increased pain. The healthcare provider should be notified immediately to initiate appropriate interventions, which may include wound cultures, antibiotics, and possibly surgical intervention to manage the infection. Monitoring the client’s temperature and other vital signs is also essential to detect systemic infection early.

Choice E: Pedal Pulses
The client’s pedal pulses are +2 bilaterally, which is considered normal. Pedal pulses are assessed to evaluate peripheral circulation, and a +2 rating indicates normal pulse strength. There is no immediate concern regarding the client’s peripheral circulation based on this finding. However, it is important to continue monitoring peripheral pulses as part of routine postoperative care to ensure there are no changes that could indicate vascular complications.

Choice A reason: Administer a test dose first

Administering a test dose is not typically required for theophylline. Theophylline dosing is usually based on the patient’s weight and serum theophylline levels. A test dose is more commonly associated with medications that have a high risk of allergic reactions or require desensitization protocols, which is not the case with theophylline.

Choice B reason: Infuse the medication with an IV pump

Using an IV pump to infuse theophylline is essential to ensure accurate and controlled delivery of the medication. Theophylline has a narrow therapeutic range, and precise dosing is crucial to avoid toxicity. An IV pump allows for consistent infusion rates, reducing the risk of adverse effects. This is the most appropriate action for the nurse to take.

Choice C reason: Cover the IV container with dark paper

There is no need to cover the IV container with dark paper when administering theophylline. Theophylline is not light-sensitive, so this precaution is unnecessary. Covering IV containers is typically done for medications that degrade when exposed to light, such as certain antibiotics and chemotherapy agents.

Choice D reason: Infuse the medication at 35 mg/min

Infusing theophylline at a rate of 35 mg/min is excessively high and could lead to severe toxicity. The infusion rate for theophylline should be carefully calculated based on the patient’s weight and serum levels, and it is typically much lower than 35 mg/min. Rapid infusion can cause serious side effects, including arrhythmias and seizures.