Nokea
A nurse is administering heparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Aspirate before injecting the medication
- B. Use a 25-gauge, 1/2-inch needle to administer the medication
- C. Administer the medications within 2 cm (1 in) of the umbilicus
- D. Massage the site after injecting the medication.
Correct Answer: B
Rationale: The correct answer is B: Use a 25-gauge, 1/2-inch needle to administer the medication. This gauge and length are appropriate for subcutaneous injections to avoid reaching muscle tissue. Using a smaller needle minimizes tissue trauma, discomfort, and the risk of bleeding. Aspiration before injecting is unnecessary for subcutaneous injections as there are no large blood vessels in the subcutaneous tissue, making it safer to skip this step. Administering the medication within 2 cm of the umbilicus is not recommended as it could lead to irritation or infection at the site. Massaging the site after injecting the medication is contraindicated as it can cause bruising or discomfort.
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A nurse is preparing to administer phenobarbital 3 mg/kg/day PO in two divided doses to a client who weighs 145 lb. The amount available is phenobarbital 100 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 1
Rationale: To determine the total daily dose, convert the client's weight from lb to kg (145 lb / 2.2 = 65.91 kg). Then calculate the total daily dose in mg (3 mg/kg/day * 65.91 kg = 197.73 mg/day). Since it is divided into two doses, the nurse should administer approximately 99 mg per dose. Since each tablet is 100 mg, the nurse should administer 1 tablet per dose. This is the correct answer, as it ensures the client receives the prescribed dose. Other choices are incorrect as they do not align with the calculated dose needed, leading to potential under or overdosing.
A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?
- A. Instruct the client's visitors not to operate the PCA pump.'
- B. Check the client's pain level every 8 hours.'
- C. Diarrhea is an adverse effect of morphine PCA.'
- D. Using morphine PCA increases the client's risk of toxicity.'
Correct Answer: A
Rationale: The correct answer is A, instruct the client's visitors not to operate the PCA pump. This is important to prevent unauthorized administration of medication by individuals who are not trained to use the PCA pump, ensuring patient safety. Checking the client's pain level every 8 hours (B) is important but not the priority in monitoring PCA. Diarrhea is not a common adverse effect of morphine PCA (C), and using morphine PCA does not inherently increase the client's risk of toxicity (D) if used appropriately.
A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following herbal supplements should the nurse include as a contraindication for this medication?
- A. Glucosamine
- B. Garlic
- C. St. John's wort
- D. Ginkgo biloba
Correct Answer: C
Rationale: The correct answer is C: St. John's wort. St. John's wort can decrease the effectiveness of digoxin, leading to reduced therapeutic effects. This is due to St. John's wort inducing the enzymes that metabolize digoxin, resulting in lower drug levels in the body. Glucosamine (A), garlic (B), and ginkgo biloba (D) do not have significant interactions with digoxin. It is important to educate the client about potential herb-drug interactions to ensure the safety and effectiveness of their treatment.
A nurse is collecting data from a client who has a new prescription for nitrofurantoin to treat a urinary tract infection. The nurse should monitor the client for which of the following adverse effects?
- A. Tinnitus
- B. Abdominal cramping
- C. Stevens-Johnson syndrome
- D. Insomnia
Correct Answer: C
Rationale: The correct answer is C: Stevens-Johnson syndrome. Nitrofurantoin can cause serious adverse effects like Stevens-Johnson syndrome, which is a severe skin reaction. This syndrome presents with flu-like symptoms, followed by a painful rash that can lead to skin peeling and blistering. It is important for the nurse to monitor the client for any signs of skin rash, especially if it is accompanied by mucous membrane involvement. Tinnitus (choice A) and abdominal cramping (choice B) are not commonly associated with nitrofurantoin. Insomnia (choice D) is also not a common adverse effect of this medication.
A nurse in a clinic is preparing to administer the measles, mumps, rubella (MMR) vaccine to a client. Which of the following findings should indicate to the nurse that the client has a contraindication for the MMR vaccine?
- A. The client had a local reaction from a previous immunization
- B. The client reports having diarrhea this morning
- C. The client is at 9 weeks of gestation
- D. The client reports an allergy to penicillin.
Correct Answer: C
Rationale: The correct answer is C: The client is at 9 weeks of gestation. Administering the MMR vaccine during pregnancy is contraindicated due to the theoretical risk of causing harm to the fetus. The live attenuated MMR vaccine should not be given to pregnant women as it may potentially harm the developing fetus. It is crucial to avoid administration during pregnancy to prevent any adverse effects on the unborn child.
Other options are incorrect because:
A: The client had a local reaction from a previous immunization - Local reactions to previous vaccines are not contraindications to receiving the MMR vaccine.
B: The client reports having diarrhea this morning - Diarrhea is not a contraindication for the MMR vaccine.
D: The client reports an allergy to penicillin - Allergy to penicillin is not a contraindication for the MMR vaccine.