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The nurse is training persons enrolled at a community center information session on administering naloxone (Narcan) to opioid overdose victims. Which information should the nurse include when teaching this group? Select all that apply.
- A. is administered by subcutaneous injection in the abdomen, thigh, or arm
- B. works instantly
- C. lasts 30 minutes
- D. can be administered by lay persons, provided they have had training
Correct Answer: C,D
Rationale: Naloxone lasts about 30 minutes and can be administered by trained laypersons (intramuscularly or intranasally, not subcutaneously). It works rapidly but not instantly.
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The nurse is caring for a client with AIDS who is diagnosed with thrush. Which instruction should the nurse give to the client's caretaker, who will be administering nystatin (Mycostatin) oral solution?
- A. take the medication before meals
- B. take the medication after meals
- C. mix the medication with orange juice
- D. take the medication at bedtime
Correct Answer: B
Rationale: Nystatin for thrush is most effective when taken after meals to ensure prolonged contact with oral mucosa.
The nurse is preparing to administer 12.4 mL of liquid medication via oral syringe. Which of the following actions by the nurse indicate an understanding of how to give oral medications via syringe?
- A. The nurse uses either an oral or parenteral syringe to administer the medication.
- B. The nurse pours 10 mL of the medication into a 30 mL medicine cup, then adds 2.4 mL with a 3 mL syringe.
- C. The nurse pours 10 mL of the medication into a 30 mL medicine cup, then adds 2.4 mL with a 5 mL syringe.
- D. The nurse pours 10 mL of the medication into a 30 mL medicine cup, then slowly adds the remainder until it is almost halfway between the 10 mL mark and 15 mL mark.
- E. None
Correct Answer: E
Rationale: None of the options are correct. Oral syringes (not parenteral, A) should be used, and the exact 12.4 mL should be drawn directly into an oral syringe for accuracy, not approximated in a cup (B, C, D). However, since a choice is required, B is closest but still incorrect due to using a cup.
The nurse is caring for an elderly client who has been taking cimetidine (Tagamet) for a year. The nurse should monitor for which central nervous system side effects? Select all that apply.
- A. tetany
- B. agitation
- C. confusion
- D. constipation
- E. disorientation
Correct Answer: B,C,E
Rationale: Cimetidine, an H2 receptor blocker, can cause CNS side effects in the elderly, including agitation, confusion, and disorientation. Tetany is related to calcium imbalances, and constipation is a gastrointestinal side effect, not CNS.
A 12-year-old client has new orders for amphetamine and dextroamphetamine (Adderall) for attention-deficit/hyperactivity disorder. The nurse should alert the client's caregivers about which adverse effect?
- A. nausea
- B. seizures
- C. weight gain
- D. constipation
Correct Answer: B
Rationale: Adderall, a stimulant, lowers the seizure threshold, making seizures a critical adverse effect to monitor, especially in children.