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ATI PHARMACOLOGY TEST BANK QUESTIONS AND VERIFIED ANSWERS
1-A client taking morphine sulfate for acute
... [Show More] pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention?
1. Ask if the client needs to use the bedpan
2. Assess the client's fluid intake
3. Assess the client's skin turgor
4. Palpate the client's suprapubic area
Explanation:
Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions.
(Option 1) While asking if a bedpan is needed is an important nursing intervention, it does not aid in the assessment of urinary retention.
(Option 2) Gathering assessment data indicating the presence of urinary retention is necessary prior to other interventions. The nurse should assess for fluid intake after assessing bladder distension.
(Option 3) The client's skin turgor is assessed after the nurse checks for urinary retention and fluid intake. There is no need to assess skin turgor until other indicators of adequate fluid intake are reviewed.
Educational objective:
Assessing the client's suprapubic area is the priority nursing action when urinary retention is suspected. Interventions are performed after a problem is identified and its cause is determined. Urinary retention is an expected side effect of opioid medications.
2-The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching?
1. "I will call my health care provider if I notice red urine or blood in my stool."
2. "I will not stop taking dabigatran even if I get a stomachache."
3. "I will place capsules in my pill box so I will not forget to take a dose."
4. "I will swallow the capsule whole with a full glass of water."
Explanation:
Thrombin inhibitors such as dabigatran (Pradaxa) reduce the risk of clot formation and stroke in clients with chronic atrial fibrillation. The nurse should educate the client about implementing bleeding precautions (eg, using a soft-bristle toothbrush, shaving with an electric razor). Dabigatran capsules should be kept in their original container or blister pack until time of use to prevent moisture contamination (Option 3).
(Option 1) Red urine or blood in the stool may indicate internal bleeding caused by thrombin inhibitors. The client should report these symptoms to the health care provider.
(Option 2) Thrombin inhibitors should only be stopped under the direction of the health care provider. The nurse should educate the client that stopping dabigatran will increase the risk for
stroke. Taking the medication with food will not affect how much is absorbed, and food or a full glass of water may prevent gastrointestinal side effects (eg, nausea, indigestion).
(Option 4) Thrombin inhibitor capsules should not be crushed or opened as crushing pills increases absorption and risk of bleeding.
Educational objective:
Thrombin inhibitors such as dabigatran reduce the risk for clots and stroke in clients with chronic atrial fibrillation. The nurse should teach the client to use bleeding precautions and monitor for symptoms of bleeding, swallow capsules whole with a full glass of water, and keep capsules in their original container until time of use.
3-A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to emphasize to the client?
1. Report for periodic laboratory tests for kidney, liver, and blood functions [
2. Store the medication in a cool, dry place away from direct heat and light
3. Take the medication after a meal to prevent gastric distress
4. Take the medication with a full glass of water and increase fluids during the day
Explanation:
Allopurinol is prescribed to prevent gout attacks (pain and inflammation in joints caused by uric acid deposits). It inhibits uric acid production and improves solubility. Allopurinol should be taken with a full glass of water, and it is very important for the nurse to educate the client about fluid intake with this medication. The client should also increase daily fluid intake as this will help prevent the formation of renal stones and promote diuresis (increase drug and uric acid excretion).
(Option 1) Biosynthesis of uric acid occurs in the liver, and antigout medications are excreted via the kidneys; therefore, liver and renal function should be checked periodically. In addition, blood counts should be monitored as some antigout medications can cause blood dyscrasias. This is important but does not have priority over the daily need for increased fluids.
(Option 2) This is a common instruction given about the storage of many medications. It helps to ensure potency of the medication and prevent deterioration.
(Option 3) Taking allopurinol with food or after a meal can help to prevent gastric upset.
Educational objective:
It is important for the nurse to educate the client taking allopurinol about drinking a full glass of water with each dose and increasing overall fluid intake. Increased fluids help to prevent renal stones and promote diuresis and uric acid excretion.
4- The nurse is passing the prescribed medications to the assigned clients. Which scheduled administrations should the nurse hold and seek clarification from the health care provider? Select all that apply.
1. Client diagnosed with cirrhosis had 2 stools today; laxative lactulose prescribed daily
2. Client is scheduled for abdominal surgery tomorrow; vitamin E PO prescribed daily
3. Client is receiving IV vancomycin infusion; mild facial flushing noted after 30 minutes [Show Less]