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A client with a history of anaphylactic reaction to penicillin receives a prescription for cephalexin 500 mg PO twice daily. Which action should the nurse take?
- A. Administer the medication as prescribed.
- B. Monitor the client for a rash or hives.
- C. Contact the healthcare provider.
- D. Give with prescribed antihistamine.
Correct Answer: B
Rationale: Cephalexin may cause cross-reactivity in penicillin-allergic clients, so monitoring for allergic reactions like rash or hives is critical. Administering without monitoring, contacting the provider immediately, or giving antihistamines prophylactically are less appropriate.
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The healthcare provider prescribes enoxaparin sodium 80 mg SUBQ twice daily. The nurse is preparing a preloaded 1 mL syringe labeled, 'Enoxaparin sodium injection, USP 60 mg/0.6 mL.' How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: Desired dose = 80 mg, Concentration = 60 mg/0.6 mL = 100 mg/mL. Volume = 80 mg / 100 mg/mL = 0.8 mL.
Review H and P, nurse's notes, flow sheet, and prescriptions. Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have only one option selected.
- A. Reported slight rectal burning sensation: Non-therapeutic side effect
- B. Large, soft stool: Therapeutic result
- C. Dizziness: Non-therapeutic side effect
- D. Pain level of 3 on a 0 to 10 pain scale: Unrelated finding
- E. 600ml of urine: Unrelated finding
- F. Abdomen soft and flat: Unrelated finding
- G. Respiratory rate 13 breaths/min: Unrelated finding
Correct Answer:
Rationale: The question refers to bisacodyl, not lactulose. A: Rectal burning is a bisacodyl side effect. B: Soft stool is the therapeutic effect. C: Dizziness may relate to morphine, not bisacodyl. D, E, F, G: Pain, urine output, abdomen, and respiratory rate are unrelated to bisacodyl.
The nurse is preparing the client's plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.
- A. Dosage in safe range
- B. Peripheral IV in large vein
- C. No known allergies
- D. Used for prophylaxis
- E. Blood urea nitrogen 17 mg/dL (6.07 mmol/L)
- F. Potassium 4.4 mEq/L (4.4 mmol/L)
Correct Answer: A,B,C,E
Rationale: A: Safe dosage prevents toxicity. B: Large vein reduces phlebitis risk. C: No allergies avoids reactions. E: Normal BUN indicates renal function for vancomycin excretion. D and F are less directly related to safety.
A young adult female client who is planning to become pregnant asks the nurse if she can continue taking isotretinoin for cystic acne. Which information is most important for the nurse to provide this client?
- A. Breastfeeding is not recommended while taking this medication.
- B. Do not take multiple vitamins that contain vitamin A while taking this drug.
- C. Baseline liver function results must be obtained during therapy.
- D. Discontinue this medication one month before attempting to conceive.
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, requiring discontinuation at least one month before conception to prevent birth defects. Breastfeeding, vitamin A, and liver monitoring are secondary concerns.
A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse?
- A. Metal hip prosthesis was placed twenty years ago.
- B. Takes metformin hydrochloride for type 2 diabetes mellitus.
- C. Report of client's sobriety for the last five years.
- D. CT scan that was performed six months earlier.
Correct Answer: B
Rationale: Metformin use requires follow-up due to the risk of lactic acidosis with contrast agents affecting renal function. Metal prostheses, sobriety, and prior CT scans are less relevant to contrast administration safety.