A client who is taking methylprednisolone reports feeling thirsty. Which action should the nurse take first?

Monitor urinary output.

Notify the healthcare provider (HCP).

Prepare to give insulin.

Obtain fingerstick blood glucose.

Answer and Explanation

The Correct Answer is D

A. Monitor urinary output: While monitoring output is important, it does not provide immediate diagnostic information regarding the cause of the client’s thirst. It is a supportive action but not the most efficient first step to investigate potential hyperglycemia.

B. Notify the healthcare provider (HCP): Notifying the HCP is appropriate if there are abnormal findings or the client’s condition worsens. However, the nurse should gather objective data—such as a blood glucose reading—before contacting the provider.

C. Prepare to give insulin: Insulin should not be administered without confirmation of elevated blood glucose. Giving insulin without verifying hyperglycemia could lead to serious complications, including hypoglycemia.

D. Obtain fingerstick blood glucose: Methylprednisolone, a corticosteroid, can raise blood glucose levels, and excessive thirst is a classic symptom of hyperglycemia. Checking the client’s blood glucose is the most appropriate first action to determine if elevated glucose is causing the symptom.

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Correct Answer is C

Explanation

A. Compress the client's nares: Compressing the nares is a technique used for nasal medication administration or controlling nosebleeds, not for sublingual or oral spray forms of nitroglycerin. This action is unrelated to nitroglycerin use for angina.

B. Observe for facial flushing: Facial flushing is a common side effect of nitroglycerin due to vasodilation. While it should be noted during monitoring, it is not the immediate next action after administration when addressing angina symptoms.

C. Advise the client to rest: Resting after nitroglycerin administration reduces myocardial oxygen demand, helping to relieve anginal pain more effectively. It also helps prevent hypotension and dizziness, which are common side effects of the medication.

D. Elevate the client's feet: Elevating the feet is typically done if hypotension occurs. It is not a standard next step immediately after giving nitroglycerin unless the client shows symptoms like syncope or significant blood pressure drops.

A. Consult with a pharmacist about scheduling the dose one hour after the client eats. B. Assign an unlicensed assistive personnel (UAP) to bring the client a glass of low fat milk. C. Withhold the medication until the client's breakfast tray is available on the unit. D. Instruct the client that it is necessary to take nothing but water with the medication.

Correct Answer is D

Explanation

A. Consult with a pharmacist about scheduling the dose one hour after the client eats: Risedronate must be taken on an empty stomach with water for proper absorption. Taking it after eating would severely reduce its effectiveness, making pharmacist consultation unnecessary at this point.

B. Assign an unlicensed assistive personnel (UAP) to bring the client a glass of low fat milk: Milk contains calcium, which can bind to risedronate and interfere with its absorption. Providing milk at the time of administration would make the medication much less effective in treating osteoporosis.

C. Withhold the medication until the client's breakfast tray is available on the unit: Administering risedronate with or immediately after food would impair absorption. Delaying the dose until after breakfast would not meet the medication's requirements for maximum efficacy.

D. Instruct the client that it is necessary to take nothing but water with the medication: Risedronate should be taken with a full glass of plain water while fasting to ensure proper absorption. After administration, the client should also remain upright for at least 30 minutes to reduce gastrointestinal irritation.

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A client who is taking methylprednisolone reports feeling thirsty. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After administering nitroglycerin spray to a client experiencing angina, which action should the nurse implement next?

Correct Answer is C

Explanation

The nurse administers risedronate to a client with osteoporosis at 0700. The client asks for a glass of milk to drink with the medication. Which action should the nurse take?

Correct Answer is D

Explanation

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