The nurse is administering a prescribed dose of dexamethasone ...

[EY67]

The nurse is administering a prescribed dose of dexamethasone (Decadron) to a client following cranial surgery. Which of the following interventions would the nurse perform to assess for a common side effect of this medication?
 
  1. Monitor for hair loss.
  2. Monitor laboratory test results for hyperkalemia.
  3. Assess for decreased skin turgor.
  4. Obtain a prescription for blood glucose monitoring.

Question 2

The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions first?
 
  1. Ensure that the client has voided.
  2. Administer all the daily medications.
  3. Practice postoperative breathing exercises.
  4. Verify that the client has not eaten for the last 24 hours.

[bblaney]

Answer to Question 1

4

Rationale: Side effects of dexamethasone (Decadron) include delayed wound healing, hyperglycemia, fluid overload, hirsutism, and hypokalemia. Therefore monitor for hair loss, monitor laboratory test results for hyperkalemia, and assess for decreased skin turgor are incorrect.

Answer to Question 2

1

Rationale: The nurse's first action is to ensure that the client has voided, if a Foley catheter is not in place. The nurse does not administer all daily medications just prior to sending a client to the OR. Rather, the physician writes a specific prescription outlining which medications may be given with a sip of water. The client has nothing by mouth for 8 hours prior to surgery, not 24. The time of transfer to the OR is not the time to practice breathing exercises. This should have been accomplished earlier.