Nokea
A nurse is caring for a client who has ulcerative colitis and is receiving sulfasalazine. Which of the following findings requires immediate intervention?
- A. Anorexia
- B. Arthralgia
- C. Nausea
- D. Wheezing
Correct Answer: D
Rationale: The correct answer is D: Wheezing. Wheezing is a sign of a severe allergic reaction to sulfasalazine, known as Stevens-Johnson syndrome, which is a medical emergency requiring immediate intervention to prevent respiratory distress and potential anaphylaxis. Anorexia, arthralgia, and nausea are common side effects of sulfasalazine but do not indicate an immediate threat to the client's well-being. Wheezing is the most critical finding that needs urgent attention.
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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 nurse is caring for a child who has recurrent otitis media. The child weighs 14.9 kg (33 lb). A prescription is written for amoxicillin 40 mg/kg PO to be given in two divided doses per day. The pharmacy provides the nurse with amoxicillin 250 mg/5 mL. How many mL of the medication should the nurse plan to administer for each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 6
Rationale: Correct Answer: 6 mL
Rationale:
1. Calculate the total daily dose of amoxicillin: 40 mg/kg * 14.9 kg = 596 mg/day
2. Since the dose is divided into two doses, each dose will be half of the total daily dose: 596 mg/2 = 298 mg
3. Determine how many mL of the 250 mg/5 mL amoxicillin solution contains 298 mg: (298 mg / 250 mg) * 5 mL = 5.96 mL
4. Round the answer to the nearest whole number, which is 6 mL.
Summary:
- Choice A: Incorrect. It lacks a calculated rationale and is not the correct answer.
- Choices B-G: Irrelevant as they are not supported by the calculations.
A nurse is preparing to insert a miconazole vaginal suppository for a client who has vulvovaginal candidiasis. Which of the following actions is appropriate for inserting this medication?
- A. Assist the client to a left lateral position.
- B. Insert the suppository along the posterior wall of the vaginal canal
- C. Apply a light coating of petroleum jelly to the suppository.
- D. Put on sterile gloves before handling the suppository.
Correct Answer: B
Rationale: The correct answer is B: Insert the suppository along the posterior wall of the vaginal canal. This is because the posterior wall of the vaginal canal allows for the suppository to be placed in the most effective location for absorption and treatment of the infection. Placing it along this wall ensures proper placement and maximum efficacy of the medication.
Choice A: Assisting the client to a left lateral position is not directly related to the correct technique for inserting the suppository.
Choice C: Applying petroleum jelly to the suppository is not necessary and may interfere with the medication's absorption.
Choice D: Putting on sterile gloves before handling the suppository is not required for this procedure as the suppository is meant to be inserted directly into the vaginal canal.
A nurse is collecting data from a client who has gout and is taking allopurinol. Which of the following adverse effects should the nurse identify as the priority to report to the provider?
- A. Rash
- B. Diarrhea
- C. Nausea
- D. Metallic taste in mouth
Correct Answer: A
Rationale: The correct answer is A: Rash. A rash could indicate a severe allergic reaction or Stevens-Johnson syndrome, a potentially life-threatening skin disorder associated with allopurinol. This adverse effect requires immediate medical attention to prevent serious complications.
B: Diarrhea, C: Nausea, and D: Metallic taste in mouth are common side effects of allopurinol but not typically considered urgent or life-threatening. Reporting them to the provider is important, but they do not require immediate attention like a rash.
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. Premedicate the client with diphenhydramine.
- B. Request a different route of administration from the provider.
- C. Administer the medication to the client.
- D. Request a different medication 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 having a severe allergy to penicillin does not contraindicate the use of erythromycin. Premedicating with diphenhydramine (Choice A) is not necessary as there is no cross-reactivity between erythromycin and penicillin. Requesting a different route of administration (Choice B) is unnecessary as the oral route is appropriate for erythromycin. Requesting a different medication (Choice D) is not required, as erythromycin is safe to use in a client with a penicillin allergy.