Nokea
The nurse has a prescription to administer hydroxyzine to a client by the intramuscular route. Before administering the medication, what information should the nurse share with the client?
- A. Excessive salivation is a side effect.
- B. There will be some pain at the injection site.
- C. There should be relief from nausea within 5 minutes.
- D. The client may experience increased agitation for about 2 hours.
Correct Answer: B
Rationale: Hydroxyzine is an antiemetic and sedative/hypnotic that may be used in conjunction with opioid analgesics for added effect. The injection can be painful. Hydroxyzine causes dry mouth and drowsiness as side effects. Agitation is not a usual side effect. Medications administered by the intramuscular route generally take 20 to 30 minutes to become effective.
You may also like to solve these questions
A client admitted to the hospital with a diagnosis of cirrhosis demonstrates massive ascites causing dyspnea. The nurse performs which intervention as a priority measure to assist the client with this complication?
- A. Repositions side to side every 2 hours
- B. Elevates the head of the bed 60 degrees
- C. Auscultates the lung fields every 4 hours
- D. Encourages deep breathing exercises every 2 hours
Correct Answer: B
Rationale: The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid in the abdomen. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures in the care of a client with ascites, but the priority measure is the one that relieves diaphragmatic pressure thus assisting effective respirations.
The client diagnosed with chronic kidney disease is scheduled for hemodialysis. When should the nurse plan to administer the client's daily dose of enalapril to ensure its effectiveness?
- A. During dialysis
- B. Just before dialysis
- C. The day after dialysis
- D. Upon return from dialysis
Correct Answer: D
Rationale: Antihypertensive medications, such as enalapril, are administered to the client after hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. There is no rationale for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure.
The nurse notes this cardiac rhythm on the cardiac monitor (refer to figure). What should the nurse interpret that the client is experiencing?
- A. Atrial fibrillation
- B. Sinus bradycardia
- C. Ventricular fibrillation (VF)
- D. Premature ventricular contractions (PVCs)
Correct Answer: D
Rationale: PVCs are abnormal ectopic beats (occurring in otherwise normal sinus rhythm) originating in the ventricles. They are characterized by an absence of P waves, wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy. In atrial fibrillation, no definitive P wave usually can be observed; only fibrillatory waves before each QRS complex are observed. In sinus bradycardia, atrial and ventricular rhythms are regular, and the rates are less than 60 beats per minute. In ventricular fibrillation, impulses from many irritable foci in the ventricles fire in a totally disorganized manner, which appears as a chaotic rapid rhythm in which the ventricles quiver.
A client is scheduled for hydrotherapy for a burn dressing change. Which action should the nurse take to ensure that the client is comfortable during the procedure?
- A. Ensure that the client is appropriately dressed.
- B. Administer an opioid analgesic 30 to 60 minutes before therapy.
- C. Schedule the therapy at a time when the client generally takes a nap.
- D. Assign an unlicensed assistive personnel (UAP) to stay with the client during the procedure.
Correct Answer: B
Rationale: The client should receive pain medication approximately 30 to 60 minutes before a burn dressing change. This will help the client tolerate an otherwise painful procedure. None of the remaining options addresses the issue of pain effectively.
A low dose of ondansetron is prescribed for a client receiving chemotherapy. The nurse anticipates that the primary health care provider will prescribe the medication by which route?
- A. Oral
- B. Intranasal
- C. Intravenous
- D. Subcutaneous
Correct Answer: C
Rationale: Ondansetron is an antiemetic used to control nausea, vomiting, and motion sickness. It is available for administration by the oral, intramuscular (IM), or intravenous (IV) routes. The IV route is the route used when relief of nausea is needed in the client receiving chemotherapy. The IM route may be used when the medication is used as an adjunct to anesthesia. Option 1 should not be used in clients who are nauseated. Options 2 and 4 are not routes of administration of this medication.