Nokea
A nurse is caring for a client who is receiving a continuous IV infusion and reports pain at the IV insertion site. The nurse observes the arm is swollen and cool to touch. After discontinuing the infusion, which of the following actions should the nurse take next?
- A. Restart the infusion in other extremity
- B. Elevate the extremity
- C. Remove the catheter
- D. Apply warm, moist compresses to the site.
Correct Answer: B
Rationale: The correct answer is B: Elevate the extremity. By elevating the extremity, the nurse can help reduce swelling and improve blood flow to the area. This can help alleviate pain and prevent further complications. Removing the catheter (choice C) is necessary but not the immediate next step. Restarting the infusion in another extremity (choice A) can exacerbate the issue. Applying warm, moist compresses (choice D) may not be appropriate if there is swelling. Make sure to monitor the client for any signs of infection or other complications.
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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 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.
A nurse is preparing to administer phenobarbital 3 mg/kg/day PO in two divided doses to a client who weighs 145 lb. The amount available is phenobarbital 100 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 1
Rationale: To determine the total daily dose, convert the client's weight from lb to kg (145 lb / 2.2 = 65.91 kg). Then calculate the total daily dose in mg (3 mg/kg/day * 65.91 kg = 197.73 mg/day). Since it is divided into two doses, the nurse should administer approximately 99 mg per dose. Since each tablet is 100 mg, the nurse should administer 1 tablet per dose. This is the correct answer, as it ensures the client receives the prescribed dose. Other choices are incorrect as they do not align with the calculated dose needed, leading to potential under or overdosing.
Nurses Notes
Plan of Care
Provider Prescriptions
Vital Signs
Admissions Assessment
6 months ago:
The client was diagnosed with epilepsy during childhood. The client reports not having seizures for 2 years. The client has weaned off all seizure medications. The client was informed to return to the office for a follow-up in 6 months and to call the office if seizure activity resumes
Today:
The client reports having a seizure this morning. Provider aware and new prescription obtained.
Click to highlight the findings that require immediate follow-up as contraindications to the prescribed prescription (phenytoin).
- A. Client is a vegetarian and takes a multivitamin daily
- B. Client reports having three to four alcoholic beverages a couple times per week
- C. Last menstrual period was 3 months ago
- D. Client takes diazepam as needed for anxiety
Correct Answer: A,B,C,D
Rationale: [1,1,1,1]
The correct answer is A, B, C, D.
A: Vegetarian diet may lack sufficient Vitamin K, which interacts with phenytoin.
B: Alcohol increases phenytoin levels, leading to toxicity.
C: Missed periods could indicate pregnancy, a contraindication for phenytoin.
D: Diazepam increases sedation when combined with phenytoin.
Incorrect choices:
E, F, G: These choices do not directly interact with phenytoin or have contraindications.
A nurse in a provider's office is collecting data from a client who continues to have a migraine headache after taking sumatriptan orally 2 hr ago. Which of the following findings is the priority for the nurse to report?
- A. Tingling sensation
- B. Hypertension
- C. Dizziness
- D. Flushing
Correct Answer: B
Rationale: The correct answer is B: Hypertension. This is the priority finding for the nurse to report because sumatriptan, a medication used for migraines, can potentially cause a rare but serious side effect of increased blood pressure. Hypertension can lead to severe complications such as stroke or heart attack. Reporting hypertension promptly allows for timely intervention to prevent harm.
Other choices are less urgent:
A: Tingling sensation is a common side effect of sumatriptan and usually resolves on its own.
C: Dizziness may occur with sumatriptan but is not as concerning as hypertension.
D: Flushing is a common side effect and does not require immediate action like hypertension.