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A nurse is collecting data from a client who is taking sumatriptan. Which of the following reports indicates a therapeutic response to the medication?
- A. Improved mood
- B. Absence of headache
- C. Increased bone mass
- D. Relief of chest pain
Correct Answer: B
Rationale: The correct answer is B: Absence of headache. Sumatriptan is commonly used to treat migraines. A therapeutic response would be the absence of headache, indicating that the medication is effectively managing the client's migraine symptoms. Improved mood (A) is not a direct indication of sumatriptan's effectiveness. Increased bone mass (C) is unrelated to sumatriptan's intended use for migraines. Relief of chest pain (D) is not a typical response to sumatriptan. Therefore, the absence of headache is the most relevant indicator of a therapeutic response to sumatriptan.
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A nurse is preparing to administer 17,000 units heparin subcutaneously. Available is heparin 20,000 units/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if applicable. Do not use a trailing zero.)
- A. 0.85
Correct Answer: A
Rationale: To calculate the mL of heparin needed, use the formula: Amount needed (17,000 units) ÷ Concentration of heparin (20,000 units/mL) = mL to administer. 17,000 ÷ 20,000 = 0.85 mL (Round to the nearest hundredth). Therefore, the correct answer is A (0.85 mL). Other choices are incorrect as they do not result from the correct calculation.
A nurse is reinforcing teaching with a client who has a new prescription for nitroglycerin transdermal patches to treat angina. The nurse should inform the client that which of the following manifestations is an adverse effect of the medication?
- A. Headache
- B. Polyuria
- C. Ringing in the ears
- D. Increased blood pressure
Correct Answer: A
Rationale: The correct answer is A: Headache. Nitroglycerin transdermal patches can cause headaches as an adverse effect due to vasodilation leading to increased blood flow to the brain. This is a common side effect that may occur in patients using nitroglycerin. Polyuria (B) and ringing in the ears (C) are not common side effects of nitroglycerin. Increased blood pressure (D) is not an adverse effect of nitroglycerin; in fact, nitroglycerin decreases blood pressure by dilating blood vessels.
A nurse working in an urgent care clinic is collecting data from a client who takes montelukast. Which of the following is an expected therapeutic effect of this medication?
- A. Improved peripheral vasodilation
- B. Reduced bronchial inflammation
- C. Neutralized gastric acid
- D. Increased WBC count
Correct Answer: B
Rationale: The correct answer is B: Reduced bronchial inflammation. Montelukast is a leukotriene receptor antagonist commonly used to treat asthma and allergic rhinitis. By blocking leukotrienes, it helps reduce bronchial inflammation, leading to improved breathing and decreased asthma symptoms. Other choices are incorrect because montelukast does not affect peripheral vasodilation, gastric acid levels, or WBC count. It is important for the nurse to recognize the expected therapeutic effects of medications to monitor and evaluate the client's response accurately.
A nurse is caring for a client who has a new prescription for a nitroglycerin transdermal patch. Which of the following actions should the nurse take?
- A. Take the patch off prior to bathing the client.
- B. Monitor for hypertension after application of the patch.
- C. Rotate the application sites of the patch.
- D. Remove the patch every 24 hr
Correct Answer: C
Rationale: The correct answer is C: Rotate the application sites of the patch. This is important to prevent skin irritation and tolerance development. By rotating the sites, the nurse ensures consistent drug absorption and effectiveness. Choice A is incorrect because removing the patch prior to bathing can disrupt drug delivery. Choice B is incorrect as nitroglycerin typically causes hypotension, not hypertension. Choice D is incorrect as nitroglycerin patches are usually left on for 12-14 hours and then replaced with a new patch.
A nurse is preparing to administer regular and NPH insulin to a client. Which of the following actions should the nurse take?
- A. Withdraw the NPH insulin last.
- B. Mix the medications in a 3-mL syringe.
- C. Administer the medications in two separate syringes.
- D. Inject air into the regular vial first.
Correct Answer: A
Rationale: The correct answer is A: Withdraw the NPH insulin last. This is because regular insulin is a clear solution and should be withdrawn first to prevent contamination with the cloudy NPH insulin. Mixing the medications in a 3-mL syringe (B) is not recommended as it may alter the effectiveness of the insulin. Administering the medications in two separate syringes (C) is important to avoid mixing them prior to administration. Injecting air into the regular vial first (D) is unnecessary and not a standard practice.