Nokea
A nurse is reinforcing teaching for a client who has angina pectoris and a new prescription to apply a nitroglycerin transdermal patch daily. Which of the following instructions should the nurse give the client?
- A. Use an old patch with medication residue on the inside and discard it in a closed receptacle.
- B. Keep a nitroglycerin patch in place for 72 hours before replacing.
- C. Apply the patch to a hairy area of the skin for better adherence.
- D. Cleanse the skin before applying a nitroglycerin patch.
Correct Answer: D
Rationale: The correct answer is D - Cleanse the skin before applying a nitroglycerin patch. This instruction is crucial to ensure proper absorption of the medication and prevent skin irritation. Cleansing the skin removes dirt, oils, and sweat, allowing the patch to adhere properly and deliver the medication effectively. Using an old patch (A) can lead to inconsistent dosing and decreased effectiveness. Keeping the patch in place for 72 hours (B) can cause skin irritation and decrease medication potency. Applying the patch to a hairy area (C) may reduce adherence and interfere with proper contact with the skin. Therefore, instructing the client to cleanse the skin before application is the most appropriate choice.
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A nurse in the emergency department is assisting with the care of a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following actions should the nurse take first?
- A. Apply a tourniquet just above the wound.
- B. Place the client in a modified Trendelenburg position.
- C. Apply pressure directly to the wound.
- D. Settle the client in a reclining position.
Correct Answer: C
Rationale: The correct action is to apply pressure directly to the wound first. This is crucial to control the bleeding and prevent further blood loss. Applying pressure helps to promote clotting and reduce the risk of hypovolemic shock. It is the immediate and most effective intervention to manage the situation.
Choice A (Apply a tourniquet just above the wound) is incorrect because tourniquets should be used as a last resort due to the risk of tissue damage and potential complications.
Choice B (Place the client in a modified Trendelenburg position) is incorrect as this position is not recommended for patients with bleeding as it can increase intracranial pressure and worsen the situation.
Choice D (Settle the client in a reclining position) is incorrect because the priority is to control the bleeding first before adjusting the client's position.
A nurse is reinforcing discharge instructions for a client who has asthma and is about to start taking theophylline. The nurse should instruct the client to monitor which of the following findings is an adverse effect of the medication.
- A. Drowsiness.
- B. Constipation.
- C. Tachycardia.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C: Tachycardia. Theophylline, a bronchodilator used in asthma, can cause tachycardia as an adverse effect due to its stimulant effect on the heart. Tachycardia is characterized by a fast heart rate, which can be concerning and may indicate an overdose or toxicity of the medication. Monitoring for tachycardia is crucial to ensure the client's safety and well-being.
Incorrect answers:
A: Drowsiness - Theophylline is a stimulant and is more likely to cause insomnia or restlessness rather than drowsiness.
B: Constipation - Constipation is not a common adverse effect of theophylline.
D: None of the above - This is incorrect as tachycardia can be an adverse effect of theophylline.
A nurse is preparing to administer insulin lispro to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse plan to take?
- A. Inject insulin lispro 15 min before a meal.
- B. Monitor the client for polyuria after the insulin lispro injection.
- C. Check the expiration date after the insulin lispro specification.
- D. Administer using a syringe with no washing.
Correct Answer: A
Rationale: The correct answer is A: Inject insulin lispro 15 min before a meal. This is because insulin lispro is a rapid-acting insulin that should be administered within 15 minutes before a meal to control postprandial glucose levels effectively. Administering it before a meal ensures that the insulin peaks when the client's blood glucose levels rise after eating, thus preventing hyperglycemia. Monitoring for polyuria (choice B) is important but not specific to insulin lispro administration. Checking the expiration date (choice C) is necessary but not directly related to the administration process. Administering insulin without washing the syringe (choice D) is incorrect as proper hygiene is essential to prevent infections.
A nurse is caring for a client who has a thrombus and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?
- A. The time it takes for heparin to dissolve a clot depends on the size of the clot.
- B. The time it takes for heparin to dissolve a clot varies between clients.
- C. Usually, it takes at least 2 to 3 days for heparin to dissolve a clot.
- D. Heparin prevents new clots from forming rather than dissolving existing ones.
Correct Answer: D
Rationale: Correct Answer: D. Heparin prevents new clots from forming rather than dissolving existing ones.
Rationale: Heparin works by inhibiting the formation of new clots rather than actively dissolving existing clots. It does not directly break down clots but rather prevents them from getting larger or new clots from forming. Therefore, it is important for the nurse to educate the client that heparin's primary function is to prevent further clot formation and not to dissolve the existing clot.
Summary of other choices:
A: The time it takes for heparin to work is not dependent on the size of the clot.
B: While response times may vary between clients, the primary action of heparin remains the same.
C: Providing a specific time frame for clot dissolution is inaccurate as heparin does not dissolve clots.
E, F, G: Options not provided.
A nurse is preparing to administer amoxicillin 250 mg PO. Available is amoxicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.).
- A. 2 mL.
- B. 5 mL.
- C. 8 mL.
- D. 10 mL.
Correct Answer: D
Rationale: To determine the correct amount of oral suspension to administer, we first need to calculate the total mL needed for 250 mg of amoxicillin. Given that the concentration is 125 mg/5 mL, we can set up a proportion: 125 mg is to 5 mL as 250 mg is to x mL. Cross multiply to find x: 125x = 250*5. Solving for x, we get x = 250*5/125 = 10 mL. Therefore, the nurse should administer 10 mL of amoxicillin oral suspension.
Choice A (2 mL) is incorrect because it is only half of the calculated amount. Choice B (5 mL) is incorrect because it does not account for the higher dosage required. Choice C (8 mL) is incorrect as it is too low based on the calculation.