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A nurse is caring for a client who is taking lisinopril (ACE inhibitor). Which of the following outcomes indicates a therapeutic effect of the medication?
- A. Improved sexual function
- B. Decreased blood pressure
- C. Increase of HDL cholesterol
- D. Prevention of bipolar manic episodes
Correct Answer: B
Rationale: The correct answer is B: Decreased blood pressure. Lisinopril is an ACE inhibitor used to treat hypertension by relaxing blood vessels, leading to decreased blood pressure. This outcome is a therapeutic effect because it helps reduce the risk of cardiovascular events. Improved sexual function (A) is not a direct effect of lisinopril. Increase of HDL cholesterol (C) is not a primary effect of ACE inhibitors. Prevention of bipolar manic episodes (D) is unrelated to the mechanism of action of lisinopril.
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A nurse is teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include?
- A. Break needles on syringes before disposal
- B. Use two hands to recap a needle after administering a medication
- C. Dispose of used razors in wastebaskets
- D. Replace sharps containers when they are 3/4 full
Correct Answer: D
Rationale: The correct answer is D: Replace sharps containers when they are 3/4 full. This instruction is crucial in preventing puncture injuries as overfilling sharps containers can increase the risk of accidental needle sticks. By replacing the containers when they are 3/4 full, it ensures that there is enough space to safely dispose of needles and other sharp objects without risking spills or injuries.
Explanation of other choices:
A: Breaking needles on syringes before disposal is unsafe as it can increase the risk of needle stick injuries.
B: Using two hands to recap a needle is dangerous and not recommended as it can lead to accidental needle sticks.
C: Disposing of used razors in wastebaskets is improper as they should be disposed of in puncture-proof containers.
Summary: Option D is the correct choice as it emphasizes safe disposal practices to prevent puncture injuries, while the other options promote unsafe practices that can increase the risk of needle stick injuries.
A nurse is preparing to administer an ophthalmic medication to a client. Which of the following actions should the nurse plan to take?
- A. Apply pressure to the client’s nasolacrimal duct after instillation
- B. Clean the client's eye from the outer canthus to the inner canthus before instillation
- C. Ask the client to tightly squeeze their eyes shut after the instillation
- D. Instill the ophthalmic medication directly on the client's cornea
Correct Answer: A
Rationale: The correct answer is A: Apply pressure to the client’s nasolacrimal duct after instillation. This action helps prevent systemic absorption of the medication and decreases the risk of side effects. By gently pressing on the nasolacrimal duct, the nurse can reduce the systemic absorption of the medication and promote its local effects. This technique is crucial for ophthalmic medications to work effectively and minimize adverse reactions.
Choice B is incorrect because cleaning the eye from outer to inner canthus can introduce contaminants into the eye, increasing the risk of infection. Choice C is incorrect as tightly squeezing the eyes shut can also lead to systemic absorption of the medication. Choice D is incorrect as instilling the medication directly onto the cornea can be harmful and may not distribute the medication effectively.
A nurse is teaching a class about pharmacodynamics. The nurse should include that which of the following medication levels occurs when a medication is at the lowest serum concentration?
- A. Trough
- B. Peak
- C. Half-life
- D. Toxic
Correct Answer: A
Rationale: The correct answer is A: Trough. The trough level represents the lowest serum concentration of a medication in the body, usually measured just before the next dose is administered. This is important in monitoring the effectiveness and safety of the drug. Peak levels (B) indicate the highest concentration. Half-life (C) refers to the time it takes for half of the drug to be eliminated from the body. Toxic levels (D) are when the drug concentration is too high and can lead to harmful effects. Other choices are not relevant to the lowest serum concentration.
A nurse is teaching a class about reducing the risk of medication errors. Which of the following information should the nurse include?
- A. Provide a dedicated area for the nurse to prepare medications
- B. Wait to document medications given to clients until the end of a shift
- C. Remove medications from automatic dispensing systems before they are reviewed by pharmacists
- D. Prepare medications for multiple clients at the same time
Correct Answer: A
Rationale: Correct Answer: A - Provide a dedicated area for the nurse to prepare medications.
Rationale: Providing a dedicated area for medication preparation helps reduce distractions and promotes focus, decreasing the likelihood of errors. This setup allows for organization and prevents cross-contamination. It also encourages proper storage and disposal of medications, fostering a safer environment for medication preparation.
Summary of Other Choices:
B: Waiting to document medications until the end of a shift can lead to errors in documentation and potential confusion. Real-time documentation is crucial for accuracy.
C: Removing medications from automatic dispensing systems before pharmacist review bypasses a critical safety check, increasing the risk of errors.
D: Preparing medications for multiple clients simultaneously can lead to mix-ups and errors, as it increases the chances of confusion and incorrect dosing.
A nurse is admitting a new client. Which of the following steps of the nursing process is the nurse performing when formulating goals to address an identified problem?
- A. Planning
- B. Implementation
- C. Assessment
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Planning. In the nursing process, planning involves formulating goals and developing a plan of action to address the identified problems from the assessment phase. During this step, the nurse sets specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided. Planning ensures that interventions are tailored to the client's unique needs and helps achieve positive outcomes. The other choices are incorrect because: B: Implementation involves carrying out the plan, C: Assessment is the initial step of gathering data, and D: Evaluation is the final step to determine the effectiveness of the interventions.