a nurse is caring for a client receiving meperidine demerol for pain management which assessment finding requires immediate action
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Nursing Elites

HESI RN

HESI Pharmacology Practice Exam

1. A client is receiving meperidine (Demerol) for pain management. Which assessment finding requires immediate action?

Correct answer: C

Rationale: A respiratory rate of 10 breaths per minute indicates respiratory depression, a severe side effect of meperidine (Demerol) that necessitates immediate intervention to prevent further complications. Constipation, drowsiness, and nausea are common but less urgent side effects that do not pose an immediate life-threatening risk. Respiratory depression can lead to respiratory arrest and must be addressed promptly to ensure the client's safety and well-being.

2. After administering acetylcysteine (Mucomyst), 20% solution diluted in 0.9% normal saline by nebulizer, the nurse should have which item available for potential use?

Correct answer: D

Rationale: Acetylcysteine is administered via inhalation as a mucolytic. It helps liquefy secretions, making it easier for the client to clear them. However, in some cases, the increased volume of liquefied secretions may be challenging for the client to manage, leading to the potential need for suction equipment to assist in clearing the airway. Therefore, the nurse should have suction equipment available after administering acetylcysteine to address any issues related to excessive secretions.

3. A client is being cared for by a nurse due to severe back pain, and codeine sulfate has been prescribed. Which of the following should the nurse include in the plan of care while the client is taking this medication?

Correct answer: B

Rationale: When a client is prescribed codeine sulfate, it is essential to monitor bowel activity because this medication can lead to constipation. Therefore, monitoring bowel function is crucial to prevent or manage any potential gastrointestinal issues that may arise.

4. A client receiving nitrofurantoin (Macrodantin) calls the health care provider's office complaining of side effects related to the medication. Which side effect indicates the need to stop treatment with this medication?

Correct answer: D

Rationale: Pulmonary reactions such as cough and chest pain are serious side effects associated with nitrofurantoin that require immediate discontinuation of the medication to prevent potential severe respiratory complications.

5. A client receives a prescription for methocarbamol (Robaxin), and the nurse reinforces instructions to the client regarding the medication. Which client statement would indicate a need for further instructions?

Correct answer: C

Rationale: The correct answer is C because blurred vision is an adverse effect of methocarbamol (Robaxin) and should be reported to a healthcare provider. Choices A, B, and D are all correct statements. Option A informs the client about a possible discoloration of urine, which is a known side effect. Option B correctly explains the purpose of the medication. Option D correctly advises the client to contact their doctor if they experience nasal congestion, which could indicate an adverse reaction.

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