Nokea
A nurse is assessing a client after administering a second dose of cefazolin IV. The nurse notes the client has anxiety, hypotension, and dyspneWhich of the following medications should the nurse administer first?
- A. Diphenhydramine
- B. Albuterol inhaler
- C. Epinephrine
- D. Prednisone
Correct Answer: C
Rationale: The correct answer is C: Epinephrine. When a client exhibits symptoms of anxiety, hypotension, and dyspnea after receiving cefazolin IV, it indicates a severe allergic reaction/anaphylaxis. Epinephrine is the first-line medication for anaphylaxis as it acts quickly to reverse the symptoms by constricting blood vessels, increasing blood pressure, and opening airways. Diphenhydramine (A) is an antihistamine that can be given as a second-line treatment. Albuterol inhaler (B) is used for bronchospasm but is not the first choice in anaphylaxis. Prednisone (D) is a corticosteroid that may be used later for inflammation but is not the initial treatment for anaphylaxis.
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A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take?
- A. Administer the medication outside the 5 cm (2 in) radius of the umbilicus.
- B. Aspirate for blood return before injecting.
- C. Rub vigorously after the injection to promote absorption.
- D. Place a pressure dressing on the injection site to prevent bleeding.
Correct Answer: A
Rationale: The correct answer is A: Administer the medication outside the 5 cm (2 in) radius of the umbilicus. This is because injecting heparin near the umbilicus can lead to bruising or hematoma formation. Subcutaneous injections are generally given in the fatty tissue of the abdomen, but it is important to avoid the area around the umbilicus to prevent discomfort and complications. Aspiration for blood return (B) is not necessary for subcutaneous injections as they are not typically administered into a blood vessel. Rubbing vigorously after the injection (C) is not recommended as it can cause tissue damage. Placing a pressure dressing on the injection site (D) is also unnecessary for subcutaneous injections.
Which of the following findings should indicate to the nurse that a client with myasthenia gravis taking neostigmine is experiencing an adverse effect?
- A. Tachycardia
- B. Oliguria
- C. Xerostomia
- D. Miosis
Correct Answer: D
Rationale: The correct answer is D: Miosis. Neostigmine is a cholinesterase inhibitor used to treat myasthenia gravis. Miosis, or excessive constriction of the pupil, is a sign of cholinergic crisis which can occur due to neostigmine overdose. This adverse effect indicates excessive stimulation of the parasympathetic nervous system, leading to symptoms such as increased salivation, bronchoconstriction, and miosis. Tachycardia (A) is not typically associated with neostigmine use, oliguria (B) is not a common adverse effect, and xerostomia (C) is the opposite of the expected effect of increased salivation due to cholinergic stimulation.
A nurse is assessing a client 1 hr after administering morphine for pain. The nurse should identify which of the following findings as the best indication that the morphine has been effective?
- A. The client's vital signs are within normal limits.
- B. The client has not requested additional medication.
- C. The client is resting comfortably with eyes closed.
- D. The client rates pain as 3 on a scale from 0 to 10.
Correct Answer: D
Rationale: Correct Answer: D. The client rates pain as 3 on a scale from 0 to 10.
Rationale: Pain assessment is subjective. The client's self-report of pain is the most reliable indicator of pain relief efficacy. A pain rating of 3 indicates that the pain has decreased from the initial level, suggesting that the morphine has been effective in managing the pain.
Summary of Other Choices:
A: The client's vital signs being within normal limits may not directly correlate with pain relief. Vital signs can be influenced by various factors other than pain relief.
B: The client not requesting additional medication does not necessarily indicate effective pain management as some individuals may hesitate to ask for more medication.
C: The client resting comfortably with eyes closed may indicate relaxation but does not specifically confirm pain relief.
E, F, G: No additional choices provided.
A nurse is preparing to administer PO sodium polystyrene sulfonate to a client who has hyperkalemiWhich of the following actions should the nurse plan to take?
- A. Hold the client's other oral medications for 1 hour post-administration.
- B. Inform the client that this medication can turn stool a light tan color.
- C. Keep the client's solution in the refrigerator for up to 72 hours.
- D. Monitor the client for constipation.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client for constipation. Sodium polystyrene sulfonate is a medication used to treat hyperkalemia by binding excess potassium in the intestines for elimination. Constipation is a common side effect, as the medication can cause a decrease in bowel motility. The nurse should monitor the client for signs of constipation, such as abdominal discomfort, decreased frequency of bowel movements, or difficulty passing stools. This is essential to prevent complications such as bowel obstruction. Holding the client's other oral medications, informing about stool color changes, or refrigerating the solution are not relevant actions for administering sodium polystyrene sulfonate.
Which of the following medications should the nurse plan to administer to a client with myasthenia gravis who is in a cholinergic crisis?
- A. Potassium Iodide
- B. Glucagon
- C. Atropine
- D. Protamine
Correct Answer: C
Rationale: Rationale:
C: Atropine is the correct answer because it is an anticholinergic medication that can counteract the excess acetylcholine causing cholinergic crisis in myasthenia gravis.
Incorrect choices:
A: Potassium Iodide is used for thyroid conditions, not for myasthenia gravis crises.
B: Glucagon is used for hypoglycemia, not for myasthenia gravis crises.
D: Protamine is used to reverse the effects of heparin, not for myasthenia gravis crises.