The nurse is caring for a client who has experienced head trauma in a motor vehicle accident.

The client is having excessive urine output.
Which medication should the nurse anticipate administering?

Prednisolone (Prelone)

Corticotropin (ACTH or adrenocorticotropic hormone)

Vasopressin (Pitressin)

Calciferol (Ergocalciferol)

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Prednisolone is a corticosteroid that has anti-inflammatory and immunosuppressant effects. It does not have a direct effect on urine output.

While it may be used in some cases of head trauma to reduce inflammation, it would not be the first-line choice to address excessive urine output.

Prolonged use of prednisolone can have adverse effects such as fluid retention, weight gain, hypertension, and hyperglycemia.

Choice B rationale:

Corticotropin (ACTH) is a hormone that stimulates the adrenal glands to produce cortisol. Cortisol has a variety of effects, including increasing blood pressure and blood sugar levels.

It does not have a direct effect on urine output and would not be used to address this issue.

ACTH can have significant side effects, including fluid retention, electrolyte imbalances, and mood changes.

Choice C rationale:

Vasopressin is a hormone that regulates fluid balance in the body. It works by increasing water reabsorption in the kidneys, which can help to reduce urine output.

It is the most appropriate medication to administer to a client with excessive urine output following head trauma.

Vasopressin can be administered intravenously or subcutaneously. It is important to monitor the client's fluid intake and output closely when administering vasopressin, as it can lead to fluid overload if not used carefully.

Choice D rationale:

Calciferol is a form of vitamin D that helps to regulate calcium and phosphorus levels in the body. It does not have a direct effect on urine output.

It would not be used to address excessive urine output in a client with head trauma.

Excessive doses of calciferol can lead to hypercalcemia, which can cause kidney stones, bone pain, and other serious problems.

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Correct Answer is B

Explanation

Choice A rationale:

Insulin lispro is a rapid-acting insulin that begins to work within 15 minutes of injection. If administered 15 minutes after eating, it may not be able to effectively control the rise in blood glucose levels that occurs after a meal. This could lead to hyperglycemia, which can have negative short-term and long-term health consequences.

Administering insulin lispro 15 minutes after eating would delay its action and potentially lead to suboptimal blood glucose control. It's crucial to match the timing of insulin administration with the meal to ensure optimal glucose management.

Choice C rationale:

Administering insulin lispro 10 minutes after eating would also delay its action. While not as delayed as 15 minutes, it still wouldn't align with the peak of meal-related glucose absorption, potentially leading to suboptimal glucose control.

Choice D rationale:

Insulin lispro has a shorter duration of action compared to regular insulin. Administering it 30 minutes before eating could lead to hypoglycemia, a condition characterized by low blood glucose levels. Hypoglycemia can cause a variety of symptoms, including shakiness, sweating, dizziness, confusion, and even loss of consciousness.

It's essential to closely align the timing of rapid-acting insulins like insulin lispro with mealtimes to minimize the risk of hypoglycemia.

A. Administer 0.4 mg of nitroglycerin SL. B. Notify the provider of the patient’s vital signs. C. Give nitroglycerin by translingual spray. D. Administer 10 units NPH insulin.

Correct Answer is B

Explanation

Rationale for Choice A:

Repeating the dose of nitroglycerin SL is not recommended at this time due to the patient's hypotension (blood pressure of 88/68 mmHg).

Administering additional nitroglycerin could further lower the blood pressure, potentially leading to adverse consequences such as dizziness, lightheadedness, or even fainting.

It's crucial to prioritize patient safety and avoid actions that could exacerbate their condition. Rationale for Choice B:

Notifying the provider is the most appropriate action in this situation for several reasons:

The patient's chest pain has not been relieved by the initial dose of nitroglycerin, indicating a need for further evaluation and potential adjustments to the treatment plan.

The patient's blood pressure is low, which warrants close monitoring and possible intervention to prevent complications.

The provider can assess the patient's overall clinical picture, including other symptoms and medical history, to determine the best course of action.

Early notification allows for timely interventions and potential prevention of further complications. Rationale for Choice C:

While nitroglycerin by translingual spray may be considered in some cases of persistent angina, it's not the most appropriate choice in this situation due to the patient's hypotension.

The translingual spray can also have a rapid onset of action, which might further lower the blood pressure if not carefully monitored.

It's essential to consider the patient's overall hemodynamic status before administering any medication that could potentially affect blood pressure.

Rationale for Choice D:

Administering NPH insulin is not relevant to the management of angina or chest pain.

Insulin is used to treat hyperglycemia in patients with diabetes, and its administration would not address the underlying issue of the patient's chest pain.

It's important to select interventions that are directly targeted at the patient's presenting symptoms and condition.

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The nurse is caring for a client who has experienced head trauma in a motor vehicle accident.The client is having excessive urine output.Which medication should the nurse anticipate administering?

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Naxlex Comprehensive Predictor Exams

A client is ordered to receive insulin lispro (Humalog) at mealtimes. When should the nurse instruct the client to administer the medication?

Correct Answer is B

Explanation

A patient with angina has been given 0.4 mg of nitroglycerin SL and reports continued chest pain 5 minutes later. The nurse assesses a heart rate of 84 beats per minute and a blood pressure of 88/68 mm Hg. What action should the nurse take next?

Correct Answer is B

Explanation

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The nurse is caring for a client who has experienced head trauma in a motor vehicle accident.

The client is having excessive urine output.
Which medication should the nurse anticipate administering?