The practical nurse (PN) is helping with the care plan for a client who is taking the nonsteroidal anti-inflammatory drug ketorolac for painful back muscle spasms.
What intervention should the PN include in the client’s care plan?
Observe the client for development of involuntary movements of the lips and tongue.
Administer the medication at least 30 minutes before the client’s meals.
Assess the skin daily for areas of ecchymosis or other signs of bleeding.
Ensure peak and trough serum levels are collected with the third dose of medication.
The Correct Answer is C
Choice A rationale
Involuntary movements of the lips and tongue are typically associated with antipsychotic medications, not nonsteroidal anti-inflammatory drugs (NSAIDs) like ketorolac15. Therefore, observing the client for these symptoms would not be a relevant intervention for a client taking ketorolac15.
Choice B rationale
Administering the medication at least 30 minutes before meals is not a specific requirement for ketorolac15. Therefore, this would not be a necessary intervention for a client taking this medication15.
Choice C rationale
Ketorolac, like other NSAIDs, can increase the risk of bleeding15. This can manifest as areas of ecchymosis (bruising) or other signs of bleeding on the skin15. Therefore, assessing the skin daily for these signs would be an important intervention for a client taking ketorolac15.
Choice D rationale
Peak and trough serum levels are typically monitored for medications with a narrow therapeutic index, such as certain antibiotics15. Ketorolac does not typically require
monitoring of serum levels15. Therefore, ensuring peak and trough serum levels are collected would not be a necessary intervention for a client taking this medication15.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Heart rate is an important vital sign to monitor in patients, but it is not the primary outcome
data to prioritize when administering a 20% mannitol intravenous (IV) solution. Mannitol is a diuretic that works by increasing the amount of urine produced. Therefore, while heart rate can be affected by fluid balance changes, it is not the most directly relevant outcome to monitor in this context.
Choice B rationale
Ankle circumference could be an indicator of peripheral edema, which might suggest fluid
overload or poor kidney function. However, in the context of mannitol administration, which is a diuretic and would be expected to decrease fluid overload, ankle circumference is not the primary outcome to monitor.
Choice C rationale
Urinary output is the correct answer. Mannitol is an osmotic diuretic that increases urine
production. It is used to reduce intracranial and intraocular pressure by drawing water out of tissues and into the bloodstream, from where it can be excreted by the kidneys. Therefore, urinary output is the most direct measure of its effectiveness and is the key outcome that should be monitored.
Choice D rationale
Dietary intake is always important to monitor in patients, especially those receiving IV
therapy, as it can impact electrolyte balance and overall health status. However, it is not the primary outcome to monitor when administering mannitol.
Correct Answer is C
Explanation
Choice C rationale
Cyclosporine is a medication used to prevent organ rejection in transplant patients. Grapefruit and grapefruit juice should be avoided by patients taking cyclosporine as it may alter the drug’s metabolism, making the drug’s actions unpredictable.
Choice A rationale
There is no specific restriction on consuming potatoes for patients taking cyclosporine.
Choice B rationale
There is no specific restriction on consuming eggs for patients taking cyclosporine.
Choice D rationale
There is no specific restriction on consuming spinach for patients taking cyclosporine.
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