Nokea
A nurse is administering phenytoin to a client. The nurse should monitor for which of the following adverse effects?
- A. Tinnitus
- B. Bleeding gums
- C. Jaundice
- D. Deep vein thrombosis
Correct Answer: B
Rationale: The correct answer is B: Bleeding gums. Phenytoin is an antiepileptic medication known to cause gingival hyperplasia, leading to bleeding gums. Monitoring for this adverse effect is crucial to prevent further complications. Tinnitus (A) is associated with aspirin overdose. Jaundice (C) is a potential adverse effect of liver-damaging medications. Deep vein thrombosis (D) is not directly related to phenytoin administration.
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A nurse is planning care for a client who has angina and a new prescription for nitroglycerin ointment. Which of the following actions should the nurse plan to take?
- A. Cover the administration area with plastic wrap.
- B. Massage the ointment into the skin.
- C. Spread the ointment in a 10 cm2 (4in2) area.
- D. Apply the ointment in a thick layer.
Correct Answer: A
Rationale: The correct answer is A. The nurse should cover the administration area with plastic wrap when applying nitroglycerin ointment to prevent accidental exposure to others and to ensure proper absorption of the medication. This step helps to enhance the drug's efficacy by promoting direct contact with the skin and preventing it from being rubbed off onto clothing or other surfaces. Massaging the ointment into the skin (B) may alter the absorption rate and distribution of the medication. Spreading the ointment in a 10 cm2 area (C) may lead to inaccurate dosing. Applying the ointment in a thick layer (D) may result in overdose or underdose due to inconsistent dosing.
A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device. Which of the following actions by the nurse requires intervention by the charge nurse?
- A. The nurse monitors the client for oversedation
- B. The nurse reassures the client that the PCA device will not cause an overdose
- C. The nurse asks the client to demonstrate dose delivery.
- D. The nurse administers a PCA dose for the client.
Correct Answer: D
Rationale: Correct Answer: D. The nurse administering a PCA dose for the client requires intervention. This is because only the client should be allowed to self-administer medication via a PCA device to ensure safety and prevent medication errors. Allowing the nurse to administer the dose goes against the principles of PCA therapy, which empowers the client to manage their pain relief within safe limits.
Choice A: Monitoring the client for oversedation is a standard nursing practice and does not require intervention.
Choice B: Reassuring the client about the PCA device is important for patient education but does not require immediate intervention.
Choice C: Asking the client to demonstrate dose delivery is a proactive approach to ensure the client understands how to use the device correctly and does not require intervention unless the client is unable to demonstrate understanding.
A nurse is collecting data from a client before administering a hepatitis B immunization. The nurse should withhold the immunization if the client is allergic to which of the following substances?
- A. Baker's yeast
- B. Nuts
- C. Wheat
- D. Egg yolk
Correct Answer: A
Rationale: The correct answer is A: Baker's yeast. Hepatitis B vaccines are produced using baker's yeast, specifically Saccharomyces cerevisiae. If a client is allergic to baker's yeast, there is a risk of an allergic reaction to the vaccine. Nuts (B), wheat (C), and egg yolk (D) are not ingredients used in the hepatitis B vaccine production, so allergies to these substances would not necessitate withholding the immunization.
A nurse in a clinic receives a telephone call from a client who has tuberculosis and was prescribed rifampin 3 days ago. The client reports, 'My saliva and tears are red. What should I do?' Which of the following responses by the nurse is appropriate?
- A. This is an expected adverse effect of the medication.'
- B. Stop taking the medication. You are having an allergic reaction.'
- C. This condition will only last a couple of days.'
- D. Taking the medication with red meat will cause this adverse effect.'
Correct Answer: A
Rationale: The correct response is A: "This is an expected adverse effect of the medication." Red discoloration of bodily fluids is a known side effect of rifampin. The medication can cause harmless discoloration of saliva, tears, sweat, and urine. It does not indicate an allergic reaction or a serious issue that requires stopping the medication. Choice B is incorrect as stopping the medication abruptly is not necessary. Choice C is incorrect as the duration of this side effect varies. Choice D is incorrect as the discoloration is not related to the consumption of red meat.
A nurse is reviewing the medication record of a client who has hypertension. Which of the following medications should the nurse administer to lower the client's blood pressure?
- A. Promethazine
- B. Amlodipine
- C. Fluconazole
- D. Phenazopyridine
Correct Answer: B
Rationale: The correct answer is B: Amlodipine. Amlodipine is a calcium channel blocker commonly used to treat hypertension by relaxing blood vessels, reducing blood pressure. It is a first-line medication for hypertension management. Promethazine (A) is an antihistamine, Fluconazole (C) is an antifungal, and Phenazopyridine (D) is a urinary analgesic, none of which are indicated for hypertension. Selecting Amlodipine aligns with evidence-based practice guidelines for hypertension management.