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A nurse is caring for a client who has a prescription for total parenteral nutrition (TPN). Which of the following routes of administration should the nurse use?
- A. Subcutaneous
- B. Intravenous
- C. Central venous access device
- D. Midline catheter
Correct Answer: C
Rationale: The correct answer is C: Central venous access device. TPN is a highly concentrated solution that provides all the nutrients a person needs intravenously. A central venous access device allows for the infusion of TPN into a large central vein, such as the superior vena cava, ensuring immediate access to the bloodstream for rapid absorption. Using other routes like subcutaneous (A), intravenous (B), or midline catheter (D) may not be suitable due to the high osmolarity of TPN, which can cause irritation and damage to smaller veins. Therefore, a central venous access device is the most appropriate and safe route for administering TPN.
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A nurse inadvertently administers 160 mg of valsartan PO to a client who was scheduled to receive 80 mg. Which of the following actions is the priority for the nurse to take?
- A. Evaluate the client for orthostatic hypotension.
- B. Monitor the client's urine output.
- C. Obtain the client's laboratory results.
- D. Check the client for nasal congestion.
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client for orthostatic hypotension. This is the priority because an overdose of valsartan, a medication used to treat hypertension, can lead to a sudden drop in blood pressure. Orthostatic hypotension is a potential complication that can result from this overdose, and it requires immediate assessment and intervention to prevent further complications such as falls or decreased perfusion to vital organs. Monitoring urine output (B) is important for some medications but is not the priority in this case. Obtaining laboratory results (C) may be necessary in the long term but is not urgent in this situation. Checking for nasal congestion (D) is not relevant to the issue at hand.
A nurse is preparing to administer potassium chloride elixir 20 mEq/day PO to divide equally every 12 hr. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose? (Round to the nearest tenth.)
Correct Answer: 7.5
Rationale: The correct answer is 7.5 mL. To determine this, first calculate the total daily dose: 20 mEq/day ÷ 2 doses/day = 10 mEq/dose. Next, find the mL per dose using the available concentration: 10 mEq ÷ 6.7 mEq/5 mL = 7.46 mL, which rounds to 7.5 mL. This ensures the patient receives the correct dose of potassium chloride elixir. Other choices are incorrect because they do not follow the correct calculation or rounding process, leading to potential under or overdosing.
A nurse is caring for a client who is taking digoxin to treat heart failure. Which of the following predisposes this client to developing digoxin toxicity?
- A. Taking a high ceiling diuretic
- B. Having a 10-year history of COPD
- C. Having a prolapsed mitral valve
- D. Taking an HMG CoA reductase inhibitor
Correct Answer: A
Rationale: The correct answer is A: Taking a high ceiling diuretic. High ceiling diuretics, such as furosemide, can lead to hypokalemia, which increases the risk of digoxin toxicity. Digoxin competes with potassium for binding sites on the Na+/K+-ATPase pump in the heart, so low potassium levels can lead to an increased concentration of digoxin in the body, predisposing the client to toxicity. Choices B, C, and D are incorrect as they do not directly impact digoxin levels or toxicity. A history of COPD (B) or a prolapsed mitral valve (C) do not specifically predispose a client to digoxin toxicity. Taking an HMG CoA reductase inhibitor (D) does not interact directly with digoxin.
A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?
- A. Apply firm pressure to the injection site following administration
- B. Administer the medication into the client's muscle
- C. Expel the air bubble from the syringe prior to injection
- D. Insert the syringe needle halfway into the client's skin
Correct Answer: A
Rationale: Correct Answer: A: Apply firm pressure to the injection site following administration.
Rationale: Applying firm pressure to the injection site following administration of enoxaparin helps minimize the risk of bleeding, as enoxaparin is an anticoagulant medication. This pressure promotes clot formation and reduces the likelihood of bruising or hematoma formation at the injection site.
Summary of other choices:
B: Administer the medication into the client's muscle - Incorrect. Enoxaparin is a subcutaneous medication, not meant for intramuscular administration.
C: Expel the air bubble from the syringe prior to injection - Good practice but not directly related to the administration of enoxaparin.
D: Insert the syringe needle halfway into the client's skin - Incorrect. The needle should be fully inserted for proper subcutaneous injection.
A nurse is planning to administer medication to an older adult client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Tilt the client's head back when administering the medications
- B. Mix the medications with a semisolid food for the client
- C. Administer more than one pill to the client at a time
- D. Place the medications on the back of the client's tongue
Correct Answer: B
Rationale: The correct answer is B: Mix the medications with a semisolid food for the client. This is the safest option for a client with dysphagia as it reduces the risk of choking or aspiration. Mixing medications with food can help make swallowing easier and safer for the client. Tilt the client's head back (A) can increase the risk of choking. Administering more than one pill at a time (C) can lead to swallowing difficulties. Placing medications on the back of the tongue (D) can trigger a gag reflex in clients with dysphagia.