Nokea
A nurse is caring for a client who has Graves' disease and is to start therapy with propylthiouracil. The nurse should expect which of the following outcomes?
- A. Increased Hct
- B. Decreased WBC count
- C. Decreased heart rate
- D. Increased blood pressure
Correct Answer: C
Rationale: The correct answer is C: Decreased heart rate. Propylthiouracil is an antithyroid medication used to treat hyperthyroidism, such as Graves' disease. It works by inhibiting the production of thyroid hormones. A decreased heart rate is an expected outcome as hyperthyroidism can cause tachycardia (increased heart rate), and treatment with propylthiouracil helps normalize heart rate.
Incorrect options:
A: Increased Hct - Propylthiouracil does not affect hematocrit levels.
B: Decreased WBC count - Propylthiouracil does not typically affect white blood cell count.
D: Increased blood pressure - Propylthiouracil does not lead to an increase in blood pressure.
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A nurse is caring for a client who is receiving filgrastim. The nurse should monitor the client for which of the following adverse effects?
- A. Hypertension
- B. Fluid retention
- C. Bone pain
- D. Hypokalemia
Correct Answer: C
Rationale: The correct answer is C: Bone pain. Filgrastim is a medication that stimulates the production of white blood cells. Bone pain is a common adverse effect because it indicates the bone marrow is producing more cells. Monitoring for bone pain is crucial to assess the effectiveness of the medication. Hypertension (A) and fluid retention (B) are not typically associated with filgrastim. Hypokalemia (D) is not a common adverse effect of filgrastim.
A nurse is caring for a client who has cellulitis and is to begin antibiotic therapy. The client has a history of anaphylactic reaction to penicillin. Which of the following medications is contraindicated for this client?
- A. Fluconazole
- B. Tetracycline
- C. Acyclovir
- D. Cephalexin
Correct Answer: D
Rationale: The correct answer is D: Cephalexin. Cephalexin is a first-generation cephalosporin antibiotic, which shares a similar beta-lactam ring structure with penicillin. Due to the client's history of anaphylactic reaction to penicillin, there is a high risk of cross-reactivity and potential severe allergic reaction if cephalexin is administered. Therefore, it is contraindicated for this client.
Choice A: Fluconazole is an antifungal medication and does not have cross-reactivity with penicillin.
Choice B: Tetracycline is a broad-spectrum antibiotic that is not related to penicillin.
Choice C: Acyclovir is an antiviral drug and is not contraindicated in a client with a penicillin allergy.
A nurse is preparing to administer enoxaparin 5,000 units subcutaneous to a client. Which of the following actions should the nurse take?
- A. Insert the needle at a 45° or 90° angle.
- B. Hold the skin taut during administration
- C. Massage the injection site after administrating the enoxaparin.
- D. Use a 4 cm (1.6in) needle
Correct Answer: A
Rationale: The correct answer is A: Insert the needle at a 45° or 90° angle. When administering enoxaparin subcutaneously, the nurse should insert the needle at a 45° or 90° angle to ensure proper delivery into the subcutaneous tissue. Angling the needle helps prevent injecting the medication too deeply or too superficially, ensuring optimal absorption and effectiveness. Holding the skin taut (choice B) is not required for subcutaneous injections. Massaging the injection site (choice C) after administering enoxaparin is not recommended as it can cause irritation or bruising. Using a 4 cm needle (choice D) is not specified for enoxaparin administration and may not be appropriate for all clients.
A nurse is checking the forearm of a client who received a tuberculin skin test 48 hr ago. Which of the following findings at the injection site should indicate to the nurse a positive result?
- A. Excoriation
- B. Firmness
- C. Ulceration
- D. Bleeding
Correct Answer: B
Rationale: The correct answer is B: Firmness. A positive tuberculin skin test is indicated by induration (firmness) at the injection site, not redness, swelling, or pain. Induration of 10mm or more is considered positive for most individuals. Excoriation (choice A) refers to scratching or scraping of the skin, not a typical sign of a positive tuberculin skin test. Ulceration (choice C) involves open sores, not related to a tuberculin skin test. Bleeding (choice D) at the injection site is not a sign of a positive result.
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.