A nurse is caring for a client who has a new prescription for a nitroglycerin transdermal patch. Which of the following actions should the nurse take?
- A. Take the patch off prior to bathing the client.
- B. Monitor for hypertension after application of the patch.
- C. Rotate the application sites of the patch.
- D. Remove the patch every 24 hr
Correct Answer: C
Rationale: The correct answer is C: Rotate the application sites of the patch. This is important to prevent skin irritation and tolerance development. By rotating the sites, the nurse ensures consistent drug absorption and effectiveness. Choice A is incorrect because removing the patch prior to bathing can disrupt drug delivery. Choice B is incorrect as nitroglycerin typically causes hypotension, not hypertension. Choice D is incorrect as nitroglycerin patches are usually left on for 12-14 hours and then replaced with a new patch.
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A nurse is preparing to administer erythromycin PO to a client who has an infection. The nurse checks the client's medical record and notes that the client has a severe allergy to penicillin. Which of the following actions should the nurse take?
- A. Request a different medication from the provider.
- B. Premedicate the client with diphenhydramine.
- C. Administer the medication to the client.
- D. Request a different route of administration from the provider.
Correct Answer: C
Rationale: Rationale: The correct action is to administer the medication to the client (Choice C) because erythromycin is not related to penicillin and is safe to use in clients with a penicillin allergy. Requesting a different medication (Choice A) may not be necessary as erythromycin is a suitable alternative. Premedicating with diphenhydramine (Choice B) is not indicated for a penicillin allergy. Requesting a different route of administration (Choice D) is unnecessary since the oral route is appropriate for erythromycin.
A nurse is collecting data from a client who has been taking methimazole for 2 months for the treatment of a thyroid imbalance. Which of the following findings indicates that the medication is effective?
- A. Weight gain
- B. Decreased menstrual flow
- C. Clear breath sounds
- D. Increased libido
Correct Answer: A
Rationale: The correct answer is A: Weight gain. Methimazole is used to treat hyperthyroidism, which often causes weight loss due to increased metabolism. If the medication is effective, the client's thyroid hormone levels should normalize, leading to a potential reversal of weight loss and even weight gain. Decreased menstrual flow (B) and increased libido (D) are not direct indicators of methimazole effectiveness. Clear breath sounds (C) could indicate improved respiratory status but are not specific to thyroid function.
A nurse is preparing to administer an insulin injection for a client. Which of the following actions should the nurse take?
- A. Administer the insulin using a tuberculin syringe at a 15° angle.
- B. Rapidly inject the insulin using a 20-gauge 1-inch needle.
- C. Insert the needle into the right thigh at a 90° angle.
- D. Slowly inject the insulin using the Z-track method.
Correct Answer: C
Rationale: The correct answer is C: Insert the needle into the right thigh at a 90° angle. When administering insulin, the thigh is a recommended site for injection due to its larger muscle mass, which helps with consistent absorption. Inserting the needle at a 90° angle ensures proper depth for subcutaneous injection. This method also minimizes the risk of injecting into a blood vessel or reaching deeper tissues. Using the right thigh allows for rotation of injection sites, preventing lipodystrophy. Administering at a 90° angle promotes optimal absorption and minimizes discomfort for the client.
Choice A is incorrect because a tuberculin syringe is not typically used for insulin administration, and a 15° angle is too shallow for a subcutaneous injection. Choice B is incorrect as a 20-gauge needle is too large for insulin injections, which are typically administered with smaller gauge needles. Choice D is incorrect as the Z-track method is not used for insulin injections, and a slow
A nurse is reinforcing teaching about phenytoin with a client who had a tonic-clonic seizure. Which of the following information should the nurse include in the teaching?
- A. Taking ginkgo biloba increases phenytoin levels.
- B. Taking phenytoin diminishes potassium levels.
- C. Monitor for gingival hyperplasia.
- D. Minimize exposure to sunlight.
Correct Answer: C
Rationale: The correct answer is C: Monitor for gingival hyperplasia. This is important because phenytoin can cause gingival overgrowth, leading to oral health issues. The nurse should educate the client to maintain good oral hygiene and visit the dentist regularly for check-ups.
A: Taking ginkgo biloba increases phenytoin levels - This statement is incorrect. Ginkgo biloba is known to interact with certain medications, but it does not specifically increase phenytoin levels.
B: Taking phenytoin diminishes potassium levels - This statement is incorrect. Phenytoin does not directly affect potassium levels. It is more likely to cause issues with calcium and vitamin D metabolism.
D: Minimize exposure to sunlight - This statement is incorrect. While some antiepileptic medications can increase sensitivity to sunlight, phenytoin is not typically associated with this side effect.
Overall, monitoring for gingival hyperplasia is the most relevant information for the client
A nurse is caring for a client who is taking allopurinol. Which of the following laboratory findings indicates the medication has been effective?
- A. Decreased triglycerides
- B. Decreased uric acid
- C. Increased albumin
- D. Increased potassium
Correct Answer: B
Rationale: The correct answer is B: Decreased uric acid. Allopurinol is used to treat high levels of uric acid in the blood, which can lead to conditions like gout. A decrease in uric acid levels indicates that the medication is effectively lowering the client's uric acid levels. Triglycerides (choice A) are not directly affected by allopurinol. Albumin (choice C) and potassium (choice D) levels are not typically influenced by allopurinol therapy.
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