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"A headache is likely due to the anxiety about the chest pain": While anxiety could contribute to headache, the most likely cause here is the nitroglycerin. It causes vasodilation, leading to an increase in blood flow to the brain, which commonly results in a headache.

"A headache indicates tolerance to the medication": Tolerance to nitroglycerin develops gradually with repeated use, making the medication less effective over time. The headache is a typical immediate side effect of nitroglycerin, not an indication of tolerance.

"A headache is an indication of an allergy to the medication": Allergic reactions to nitroglycerin are very rare and typically involve skin reactions such as a rash. A headache, especially after taking nitroglycerin, is an expected side effect than an allergic reaction.

"Do not perform reconciliation for a client at discharge from a health care facility": Medication reconciliation is essential at discharge to ensure clients have the correct medications and avoid errors.

"Provide a list of the client's current medications during the change of shift report": While communication during shift change is important, medication reconciliation is typically done at admission, transfer, and discharge, not during routine shift reports.

"Do not include over-the-counter medications in the medication reconciliation report": Over-the-counter medications must be included in the reconciliation process. They can interact with prescribed medications and affect treatment outcomes.

"Prevention of opportunistic infections": Sucralfate is not an antimicrobial agent. It does not have a role in preventing infections. Instead, it works by forming a protective barrier over ulcers in the gastrointestinal tract, which helps in healing rather than preventing infections.

"Improvement of impaired vision": Sucralfate has no impact on vision. It is specifically used for gastrointestinal issues, such as ulcers and gastritis, and does not affect visual acuity or conditions related to vision.

"Alleviate Helicobacter pylori": While sucralfate helps protect the stomach lining, it does not directly treat Helicobacter pylori infection. Treatment of H. pylori typically involves antibiotics and proton pump inhibitors, not sucralfate.

"Drowsiness": Drowsiness is not typically associated with levothyroxine overdose. Levothyroxine is intended to increase metabolism, so drowsiness would more likely be a sign of inadequate dosing or hypothyroidism, not an overdose.

"Constipation": Constipation is generally a symptom of hypothyroidism or insufficient thyroid hormone levels. Levothyroxine overdose would usually lead to symptoms of hyperthyroidism such as increased GI motility, not include constipation.

"Hypoactive deep-tendon reflexes": Hypoactive deep-tendon reflexes are often seen in hypothyroidism, not hyperthyroidism. Levothyroxine overdose leads to symptoms of hyperthyroidism, such as nervousness, tachycardia, and insomnia, rather than sluggish reflexes.

"I’ll dial 911 if 1 nitroglycerin tablet does not relieve my pain, and then take up to 2 more tablets 5 minutes apart while waiting.": The client should not take more than 3 tablets in a 15-minute period. After the third dose, the client should immediately call 911.

"I’ll dial 911 if I still have pain after taking 4 nitroglycerin tablets over a 20-minute period.": Taking more than 3 nitroglycerin tablets in a 15-minute period is not recommended. If pain persists after the third tablet, the client should call 911.

"I’ll dial 911 when I have pain and then take the nitroglycerin tablets.": The correct sequence is to take a nitroglycerin tablet first, wait 5 minutes, and if pain continues, take another tablet. Calling 911 should only occur if pain persists after the third dose.

Notify the nurse manager: While the nurse manager should be informed of the mistake, the immediate priority is the safety of the client. The client’s risk of hypoglycemia must be addressed first before reporting the incident.

Give the client 15 to 20 g of carbohydrate: This action would be necessary if the client begins to show signs of hypoglycemia, but it is not the priority action at this moment. First, the client should be closely monitored for symptoms of hypoglycemia to determine if carbohydrates are needed.

Complete an incident report: Completing an incident report is a necessary step after the event, but the immediate priority is ensuring the client’s safety by monitoring for hypoglycemia. This can be done after the client is stable.

Dental examination: While dental health is important, it is not a necessary baseline examination before starting atorvastatin. Atorvastatin primarily affects lipid levels and liver function, so a dental exam is not part of the baseline assessments.

Hearing test: A hearing test is not required as part of the baseline examination for atorvastatin use. While statins can occasionally cause auditory issues, this is not a common or expected side effect, so a hearing test is not a routine assessment.

Papanicolaou test: A Papanicolaou (Pap) test is important for cervical cancer screening but is unrelated to starting atorvastatin. It is not considered a necessary baseline test when beginning this medication.

A. Expect urine to turn dark orange: This is not a common side effect of ciprofloxacin. Some medications, like rifampin, can cause urine discoloration, but ciprofloxacin does not typically result in dark orange urine.
B. Take this medication with an antacid: Ciprofloxacin should not be taken with antacids as they can interfere with its absorption, reducing its effectiveness. It’s important to take ciprofloxacin on an empty stomach, at least 2 hours before or 6 hours after taking antacids.
C. Drink 1,000 milliliters of fluid daily: The exact amount of fluid needed varies depending on the individual. The nurse should recommend drinking plenty of fluids, but 1,000 milliliters may not be sufficient for everyone, especially those with higher fluid needs.
D. Monitor for tendon pain: Ciprofloxacin is associated with an increased risk of tendonitis and tendon rupture, particularly in older adults and those taking corticosteroids. Clients should be advised to monitor for signs of tendon pain, swelling, or rupture.

A. Expect urine to turn dark orange: This is not a common side effect of ciprofloxacin. Some medications, like rifampin, can cause urine discoloration, but ciprofloxacin does not typically result in dark orange urine.
B. Take this medication with an antacid: Ciprofloxacin should not be taken with antacids as they can interfere with its absorption, reducing its effectiveness. It’s important to take ciprofloxacin on an empty stomach, at least 2 hours before or 6 hours after taking antacids.
C. Drink 1,000 milliliters of fluid daily: The exact amount of fluid needed varies depending on the individual. The nurse should recommend drinking plenty of fluids, but 1,000 milliliters may not be sufficient for everyone, especially those with higher fluid needs.
D. Monitor for tendon pain: Ciprofloxacin is associated with an increased risk of tendonitis and tendon rupture, particularly in older adults and those taking corticosteroids. Clients should be advised to monitor for signs of tendon pain, swelling, or rupture.

A. Expect urine to turn dark orange: This is not a common side effect of ciprofloxacin. Some medications, like rifampin, can cause urine discoloration, but ciprofloxacin does not typically result in dark orange urine.
B. Take this medication with an antacid: Ciprofloxacin should not be taken with antacids as they can interfere with its absorption, reducing its effectiveness. It’s important to take ciprofloxacin on an empty stomach, at least 2 hours before or 6 hours after taking antacids.
C. Drink 1,000 milliliters of fluid daily: The exact amount of fluid needed varies depending on the individual. The nurse should recommend drinking plenty of fluids, but 1,000 milliliters may not be sufficient for everyone, especially those with higher fluid needs.
D. Monitor for tendon pain: Ciprofloxacin is associated with an increased risk of tendonitis and tendon rupture, particularly in older adults and those taking corticosteroids. Clients should be advised to monitor for signs of tendon pain, swelling, or rupture.

Insulin detemir: Insulin detemir is a long-acting insulin that provides basal coverage and is not appropriate for the immediate treatment of diabetic ketoacidosis (DKA). DKA requires rapid-acting insulin to quickly lower blood glucose and address the acidosis.

NPH insulin: NPH insulin is an intermediate-acting insulin that has a slower onset and longer duration. It is not suitable for the rapid treatment of DKA, which requires fast-acting insulin to correct hyperglycemia and acidosis quickly.

Insulin glargine: Insulin glargine is another long-acting insulin that provides basal insulin coverage. Like insulin detemir, it is not suitable for the immediate treatment of DKA, as it does not work quickly enough to address the urgent needs of this condition.

Explain the purpose for the medications: While it is important to explain the purpose of medications, this action should follow after understanding the client's reasons for refusal. Addressing the client's concerns first allows the nurse to tailor the explanation effectively.

Document that the client refuses the medications: While documentation is important if the client refuses medication, it should not be the first action. The nurse should first engage with the client to explore the reasons for refusal before documenting it.

Tell the client the physician wants him to take the medications: This action may not address the underlying concerns. Engaging with the client to understand their reasons for refusal promotes collaborative decision-making and patient-centered care.