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A nurse is reviewing the medication administration record (MAR) of a client who requires fluticasone MDI one puff and albuterol MDI two puffs. Which of the following actions should the nurse plan to take? Place the following steps in the correct order. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)

A.

Have the client take one puff of albuterol

B.

Have the client rest for 1 min

C.

Have the client take the second puff of albuterol

D.

Have the client rest for 5 min

E.

Have the client take one puff of fluticasone

Answer and Explanation

The Correct Answer is A, B, C, D, E

Rationale:

  • Administering albuterol first is crucial because it is a bronchodilator that will help open the airways before administering the anti-inflammatory fluticasone.

 

  • The client should rest for 1 minute between puffs of albuterol to allow for the medication to take effect.

 

  • After taking the second puff of albuterol, a longer rest of 5 minutes allows the client to experience the full effects of the bronchodilator.

 

  • Finally, administering fluticasone afterward will help reduce inflammation in the airways, maximizing the benefit of both medications.


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Correct Answer is A

Explanation

Rationale:

A. Increase fluids while taking the medication: Amitriptyline is a tricyclic antidepressant that can cause anticholinergic side effects such as dry mouth and constipation. Increasing fluid intake helps to mitigate these effects and prevent dehydration and constipation.

B. Expect an elevation in blood pressure with initial doses of the medication: Amitriptyline can cause orthostatic hypotension rather than elevated blood pressure. Clients should be informed about the risk of dizziness or fainting.

C. Stop the medication immediately if urine becomes orange in color: Orange urine is not a common side effect of amitriptyline. Clients should not stop the medication without consulting their provider.

D. Take the medication in the morning: Amitriptyline has sedative effects and is typically taken at night to help manage sleep disturbances and reduce daytime drowsiness.

Correct Answer is A

Explanation

Rationale:

A. Nitrofurantoin can cause brown-colored urine due to its pigment, and clients should be informed to report this as a common side effect and not a cause for alarm.

B. Nitrofurantoin is an antibiotic used to treat urinary tract infections and does not provide relief for peripheral nerve pain.

C. Nitrofurantoin should not be crushed, as it can affect the medication's absorption and effectiveness.

D. A cough is not a typical side effect of nitrofurantoin; however, if the client develops a cough, it could be a sign of a serious side effect, and they should notify the provider.

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