Nokea
A nurse assessing a client's IV catheter insertion site notes a hematoma. Which of the following actions should the nurse take? (Select all that apply.)
- A. Stop the infusion.
- B. Apply alcohol to the insertion site.
- C. Apply warm compresses to the insertion site
- D. Lower the client's arm.
Correct Answer: C
Rationale: Warm compresses and elevation reduce swelling and promote absorption of a hematoma.
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The MMR vaccine is not recommended for pregnant women because:
- A. Pregnant women do not build adequate immunity to the vaccine
- B. There is a risk of the pregnant women developing measles encephalopathy
- C. There is a risk of the fetus developing congenital rubella syndrome
- D. Pregnant women can receive the MMR vaccine
Correct Answer: C
Rationale: MMR (live vaccine) risks fetal congenital rubella syndrome ; pregnancy contraindicates it, not immunity or encephalopathy .
Which antiepileptic drug does not act as GABA agonist?
- A. Phenytoin
- B. Sodium valproate
- C. Diazepam
- D. Phenbarbitone
Correct Answer: A
Rationale: Phenytoin blocks sodium channels, not GABA-related.
The nurse is preparing to administer Lanoxin to a patient on the telemetry unit. In addition to understanding the patient's diagnosis, the nurse must also know which characteristic(s) of the medication?(Select one that does not apply.)
- A. Chemical composition
- B. Adverse effects
- C. Expected actions
- D. Contraindications for use
Correct Answer: A
Rationale: The nurse must understand the individual patient's diagnosis and symptoms that correlate with the rationale for drug use. The nurse should also know why a medication is ordered, expected actions, usual dosing, proper dilution, route and rate of administration, adverse effects, and contraindications for the use of a particular drug. It is not required that the nurse know the chemical composition of the medication prior to administration.
The patient is taking low dose aspirin daily for his heart. The nurse knows only a portion of the medication taken actually reaches the tissue due to what process?
- A. Distribution
- B. First-pass effect
- C. Reduced absorption
- D. Gastrointestinal circulation
Correct Answer: B
Rationale: Drugs that are taken orally are usually absorbed from the small intestine directly into the portal venous system and then delivers these absorbed molecules into the liver, which immediately break the drug into metabolites, some of which are active and cause effects in the body, and some of which are deactivated and can be readily excreted from the body. As a result, a large percentage of the oral dose is destroyed at this point and never reaches the tissues. This process is not caused by distribution, absorption, or gastrointestinal circulation.
A nurse is teaching the parents of a child who has a new prescription for Desipramine. The nurse should instruct the parents that which of the following adverse effects is the priority to report to the provider?
- A. Constipation
- B. Suicidal thoughts
- C. Photophobia
- D. Dry mouth
Correct Answer: B
Rationale: Suicidal thoughts are a critical adverse effect of tricyclics like desipramine, requiring immediate reporting.