Question: When a client is taking theophylline (Theo-Dur), which is the highest priority for the nurse to include in the plan of care?
1. Restrict the client's fluid intake.
2. Instruct the client to report lethargy and fatigue.
3. Assess the client for hypertension and polyuria.
4. Monitor the client for therapeutic plasma levels of the drug.
Rationale: Theophylline (Theo-Dur) has a narrow therapeutic range (10-20 mcg/mL); therefore serum levels should be monitored and dosage adjusted accordingly to achieve efficacy and to prevent toxicity. A client taking theophylline (Theo-Dur) should maintain adequate fluid intake (1). The client should be instructed to report signs of toxicity, including nausea, vomiting, tremors, nervousness, and seizures. Lethargy and fatigue (2), or hypertension and polyuria (3) are not associated signs of theophylline toxicity.
Cognitive Level: Analysis
Nursing Process: Planning
NCLEX® Test Plan Category: Physiological Integrity
This week’s NCLEX exam practice question came from:
Manno: Mosby' s Review Cards for the NCLEX-RN® Examination, 3rd edition, Card 160; question 105
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