Nokea
A nurse is caring for a client who has asthma. The client asks the nurse how albuterol helps his breathing. Which of the following information should the nurse include in the response? (Select all that apply).
- A. The medication will increase the amount of mucus.
- B. The medication will prevent wheezing.
- C. The medication will open the airways.
- D. The medication will decrease coughing.
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D. Albuterol helps breathing by preventing wheezing (B), opening the airways (C), and decreasing coughing (D). Wheezing is caused by narrowed airways due to inflammation in asthma, so preventing it helps improve airflow. Opening the airways allows more air to enter the lungs, making breathing easier. Decreasing coughing helps reduce airway irritation and allows for better lung function. Choice A is incorrect as albuterol does not increase mucus production; it actually helps to decrease it by reducing inflammation. Choices E, F, and G are not applicable as they were left blank.
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A nurse is preparing to administer dexamethasone 3 mg PO. Available are dexamethasone 1.5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.).
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: The correct answer is B: 2 tablets. To achieve a total of 3 mg of dexamethasone, the nurse will need to administer 2 tablets of 1.5 mg each. This is calculated by dividing the total dose needed (3 mg) by the strength of each tablet (1.5 mg). Dividing 3 mg by 1.5 mg gives us 2 tablets. Therefore, the nurse should administer 2 tablets to achieve the desired dose of 3 mg.
Choice A (1 tablet) is incorrect because 1 tablet would only provide 1.5 mg of dexamethasone, which is less than the required dose of 3 mg. Choices C (3 tablets) and D (4 tablets) are incorrect as they would result in an overdose, exceeding the required dose of 3 mg.
A nurse is preparing to administer heparin subcutaneously to a client who has deep vein thrombosis. Which of the following actions should the nurse take?
- A. Insert the needle at a 90-degree angle.
- B. Massage the injection site after administering the heparin.
- C. Prepare for a blood test prior to injecting the heparin.
- D. Select a 22-gauge needle for heparin administration.
Correct Answer: A
Rationale: Correct Answer: A: Insert the needle at a 90-degree angle.
Rationale: When administering heparin subcutaneously, the nurse should insert the needle at a 90-degree angle to ensure proper delivery of the medication into the subcutaneous tissue. This angle allows for optimal absorption and effectiveness of the medication. Additionally, it minimizes the risk of injecting the medication into muscle tissue, which could lead to complications.
Summary of other choices:
B: Massaging the injection site after administering heparin is not recommended as it can cause bruising or discomfort.
C: There is no need to prepare for a blood test prior to injecting heparin subcutaneously.
D: A 22-gauge needle is too large for subcutaneous injection and can cause pain and tissue damage.
A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min. (Round to the nearest whole number.).
- A. 100 gtt/min.
Correct Answer: A
Rationale: The correct answer is A: 100 gtt/min. To calculate the IV flow rate, we first convert the prescribed volume (100 mL) and time (60 min) to drop factor per minute. 100 mL / 60 min = 1.67 mL/min. Then, we convert mL to drops using the drop factor (60 gtt/mL): 1.67 mL/min * 60 gtt/mL = 100.2 gtt/min. Rounding to the nearest whole number, the nurse should set the IV flow rate to 100 gtt/min.
Other choices (B-G) are incorrect as they are not calculated based on the given information and would lead to incorrect infusion rates.
A nurse is reviewing laboratory data from a client who has a pulmonary embolism and is receiving IV heparin. Which of the following findings should the nurse report to the provider?
- A. Patient's platelets 100,000.
- B. Prothrombin time (PT) 12 seconds.
- C. Thrombin time (TT) 55 seconds.
- D. Hematocrit 35%.
Correct Answer: A
Rationale: The correct answer is A: Patient's platelets 100,000. In a client receiving IV heparin for a pulmonary embolism, a platelet count of 100,000 indicates potential heparin-induced thrombocytopenia, a serious adverse effect that can lead to thrombosis. Thrombocytopenia increases the risk of bleeding. This finding needs immediate attention from the provider to prevent complications. The other choices are incorrect because B (PT) and C (TT) are not directly related to heparin therapy monitoring, and D (Hematocrit) does not indicate a potential adverse effect of heparin therapy like thrombocytopenia does.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for lispro and Lantus insulins. Which of the following statements by the client indicates an understanding of the teaching?
- A. Insulin injected into the thigh is the most rapidly absorbed.
- B. Should shake the bottle of insulin before withdrawing the medication.
- C. Unopened vials of insulin should be kept in the refrigerator.
- D. All insulin types can be mixed together in the same syringe.
Correct Answer: C
Rationale: The correct answer is C: Unopened vials of insulin should be kept in the refrigerator. This is correct because insulin should be stored in the refrigerator to maintain its potency and effectiveness. Insulin that is not stored properly can lose its effectiveness.
Choice A is incorrect because insulin injected into the abdomen is actually the most rapidly absorbed due to the larger surface area and increased blood flow in that area.
Choice B is incorrect because shaking the bottle of insulin can cause air bubbles to form, which can affect the accuracy of the dosage.
Choice D is incorrect because not all insulin types can be mixed together in the same syringe. It is important to consult with a healthcare provider before mixing different types of insulin.
In summary, choice C is correct because proper storage of insulin is essential for maintaining its effectiveness, while the other choices are incorrect due to various reasons related to insulin administration and storage.