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A nurse in a provider's office is collecting data from a client who continues to have a migraine headache after taking sumatriptan orally 2 hr ago. Which of the following findings is the priority for the nurse to report?
- A. Tingling sensation
- B. Hypertension
- C. Flushing
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Hypertension. The priority for the nurse to report is hypertension because sumatriptan can potentially cause an increase in blood pressure as a side effect. Hypertension is a serious condition that can lead to complications if not managed promptly.
A: Tingling sensation is a common side effect of sumatriptan and may not be immediately concerning.
C: Flushing is also a common side effect of sumatriptan and is usually not a priority.
D: Dizziness is a less severe side effect compared to hypertension and can often be managed with rest.
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A nurse is reinforcing teaching with a client who has motion sickness and a new prescription for a transdermal patch of scopolamine. The nurse should instruct the client to monitor for which of the following adverse effects?
- A. Diarrhea
- B. Bruising
- C. Jaundice
- D. Drowsiness
Correct Answer: D
Rationale: The correct answer is D: Drowsiness. Scopolamine is an anticholinergic medication commonly used to treat motion sickness. One of the common side effects of anticholinergics is drowsiness. This occurs due to the central nervous system depressant effects of the medication. Monitoring for drowsiness is important as it can impact the client's ability to drive or operate machinery safely.
A: Diarrhea is not a common side effect of scopolamine.
B: Bruising is not a common side effect of scopolamine.
C: Jaundice is not a common side effect of scopolamine.
A nurse is reinforcing teaching with a young adult client who has a new prescription for ear drops. Which of the following instructions should the nurse include?
- A. Chill the medication prior to instillation.
- B. Press a cotton ball firmly in ear canal after administering drops.
- C. Pull the pinna up and back to administer medication.
- D. Place an applicator into the ear canal to instill drops.
Correct Answer: C
Rationale: The correct answer is C: Pull the pinna up and back to administer medication. This instruction is correct because pulling the pinna up and back helps straighten the ear canal in adults, allowing the drops to be instilled properly. This technique ensures that the medication reaches the desired target area for optimal effectiveness.
Explanation of other choices:
A: Chilling the medication is not necessary and can cause discomfort to the client.
B: Pressing a cotton ball firmly in the ear canal can prevent the drops from reaching the ear canal.
D: Placing an applicator into the ear canal can cause injury or damage to the ear canal and eardrum.
A nurse is collecting data from a client who was taking oxycodone four times a day for chronic pain and reports discontinuing the medication 10 days ago. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Constricted pupils
- C. Insomnia
- D. Constipation
Correct Answer: C
Rationale: The correct answer is C: Insomnia. When a client discontinues oxycodone, a narcotic analgesic, they may experience withdrawal symptoms such as insomnia due to the abrupt cessation of the medication affecting the central nervous system. Hypotension (A) is not typically a withdrawal symptom of oxycodone. Constricted pupils (B) are a sign of opioid intoxication, not withdrawal. Constipation (D) is a common side effect of opioid use but is not a typical withdrawal symptom in this scenario.
A nurse is reinforcing teaching with a client who will be self-administering enoxaparin subcutaneously using prefilled syringes. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will use my upper arms for injections.
- B. I will massage the site after injecting the medication.
- C. I will expel the air bubble from the syringe before injecting the medication.
- D. I will pinch up the skin before injecting the medication.
Correct Answer: D
Rationale: Correct Answer: D. "I will pinch up the skin before injecting the medication."
Rationale: Pinching up the skin before injecting enoxaparin helps ensure proper subcutaneous injection technique, reducing the risk of injecting into muscle or causing discomfort. Pinching up the skin creates a subcutaneous tissue fold, providing a proper injection site and allowing for the medication to be delivered effectively. This step also minimizes the risk of bruising and ensures the medication is absorbed appropriately.
Summary of other choices:
A: Incorrect - Using upper arms for injections is not recommended for subcutaneous injections like enoxaparin.
B: Incorrect - Massaging the site after injecting can disrupt the medication's absorption and is not recommended.
C: Incorrect - Expelling air bubbles is important for intramuscular injections but not necessary for subcutaneous injections like enoxaparin.
A nurse is assisting in the development of an in-service about the varicella vaccine. The nurse should include which of the following examples as a contraindication for receiving the vaccine?
- A. A client who is breastfeeding
- B. A client who has an allergy to latex
- C. A client who has a sinus infection
- D. A client who is pregnant
Correct Answer: D
Rationale: The correct answer is D: A client who is pregnant. Varicella vaccine is contraindicated during pregnancy due to potential risks to the fetus. Varicella vaccine is a live vaccine and can pose a risk of transmission to the fetus, potentially causing harm. Other choices are incorrect because: A: Breastfeeding is not a contraindication for varicella vaccine. B: Latex allergy is not a contraindication for varicella vaccine. C: Sinus infection is not a contraindication for varicella vaccine.